The Affordable Care Act &
Racial and Ethnic
Health Equity Series
Report No. 3
Enhancing and Diversifying the
Nation’s Health Care Workforce
Final Report
September 2013
Dennis P. Andrulis
Andrulis, PhD, MPH
Nadia J. Siddiqui, MPH
Maria R. Cooper, MA
Lauren R. Jahnke, MPAff
Funded by W.K. Kellogg Foundation and The California Endowment
Developed by:
Texas Health Institute
8501 North MoPac, Suite 300
Austin, Texas 78759
To obtain a copy of the report online, visit:
http://www.texashealthinstitute.org/health-care-reform.html
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Table of Contents
Preface .......................................................................................................................................v
Executive Summary ................................................................................................................ vi
I. Introduction ......................................................................................................................... 16
II. Methodology....................................................................................................................... 21
III. Implementation Progress ................................................................................................. 23
A. Increasing Supply and Diversity of Health Care Professionals .................................... 23
•
Physicians and Physician Assistants.................................................................... 25
•
Dentists ................................................................................................................ 29
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Nurses ................................................................................................................... 31
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Mental Health Providers ...................................................................................... 35
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Long Term Care Providers ................................................................................... 38
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Community Health Workers ...............................................................................39
B. Workforce Support for the Health Care Safety Net ......................................................42
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National Health Service Corps............................................................................. 43
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Graduate Medical Education ...............................................................................45
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Area Health Education Center............................................................................ 49
C. Cultural Competency Education and Training ............................................................. 51
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Cultural Competency in Geriatric and Long Term Care .................................... 55
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Model Cultural Competency Curricala ...............................................................56
D. Health Care Workforce Evaluation and Assessment ....................................................59
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National Health Care Workforce Commission ...................................................59
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State Health Care Workforce Development Grants ........................................... 61
E. Health Care Workforce Investment in Academic Settings ...........................................65
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Historically Black Colleges and Universities & Minority-Serving Institutions .65
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Centers of Excellence .......................................................................................... 68
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Health Care Professions Training for Diversity ..................................................70
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IV. Renewed Opportunities and Remaining Challenges ...................................................... 73
V. Moving Forward ................................................................................................................78
VI. Conclusion .........................................................................................................................87
Appendix A. Key Informants & Contributors ....................................................................... 88
Appendix B. ACA Workforce Diversity Progress At-A-Glance ............................................ 92
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Preface
Data, research, and experience have demonstrated longstanding and extensive disparities in
access to, quality, and outcomes of care for racially, ethnically, and linguistically diverse patients
and communities in the U.S. health care system, despite efforts to address them. While lack of
health insurance is a well established and major contributor to these disparities, children and
adults from diverse racial and ethnic heritage often face significantly poorer care and health
outcomes than white patients even when insured.
The Patient Protection and Affordable Care Act of 2010 and the Health Care and Education
Reconciliation Act of 2010 (together the Affordable Care Act or “ACA”) offer an unprecedented
opportunity to bridge this divide. While expanding health insurance is a centerpiece in achieving
this goal, the ACA includes dozens of provisions intended to close these gaps in quality and
outcomes for racially and ethnically diverse and other vulnerable populations. In so doing, the
new law provides important incentives and requirements to create a more equitable health care
system by expanding the number of health care settings nearer to where people live and work,
increasing diversity among health professionals, and addressing language and culture in delivery
of services through innovative, clinical, and community-based approaches. But taking this vision
and its well intentioned goals to reality in the short and longer-term will determine ultimate
effectiveness and success.
The Texas Health Institute (THI) received support from the W.K. Kellogg Foundation and The
California Endowment to monitor and provide a point-in-time portrait of implementation
progress, opportunities, and challenges of the ACA’s provisions specific to or with relevance for
advancing racial and ethnic health equity. Given that the ACA was intended to be a
comprehensive overhaul of the health care system, we established a broad framework for analysis,
monitoring and assessing the law from a racial and ethnic health equity lens across five topic
areas:
• Health insurance exchanges;
• Health care safety net;
• Workforce support and diversity;
• Data, research and quality; and
• Public health and prevention.
This report is one of five THI has issued as part of the Affordable Care Act &Racial and Ethnic
Health Equity Series, and it focuses specifically on provisions in the ACA for Enhancing and
Diversifying the Health Care Workforce.
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Executive Summary
I. Introduction
Research to date reveals that the lack of diversity in the health care workforce is a significant
challenge to meeting the needs of racially and ethnically diverse populations who experience clear
and persistent disparities in health and health care. There is emerging consensus that a health
care workforce that is reflective of the patients it serves is essential for high quality and culturally
competent care. However, much work still needs to be done to achieve the goal. As recent data
confirm, the composition of the health care workforce is not reflective of the changing and
diversifying population dynamics and many diverse population groups (e.g., African Americans,
Hispanics, and Native Americans) remain significantly under-represented in the health
professions.
With the advent of health care reform, renewed opportunities for enhancing and expanding
existing programs as well as explicitly addressing workforce diversity have emerged. The ACA
includes numerous provisions that reauthorize various programs under Titles VII and VIII of the
Public Health Service Act as well as authorize several new initiatives to support a diverse and
culturally competent workforce. Understanding the status and progress of such provisions in
terms of support, funding, and implementation is critical to assuring this priority is fully realized
to advance and achieve health equity.
The purpose of this report is to provide a point-in-time status and progress update on the
implementation of the ACA’s provisions for supporting a more diverse and culturally competent
health care workforce. As such, it describes the opportunities presented by the new law, along
with challenges, lessons learned, and potential next steps for successfully implementing major
provisions of the law critical for advancing diversity and equity in health care. Embedded within
this report are emerging programs, best practices, and resources that address workforce diversity,
cultural competency training, and related efforts.
II. Methodology
We identified and monitored 19 provisions which explicitly mention or have significant relevance
for advancing racial and ethnic health equity. The provisions were organized into five topic areas:
A. Increasing supply and diversity in the health professions;
B. Workforce support for the health care safety net;
C. Cultural competency education and training;
D. Health care workforce investment in academic settings; and
E. Health workforce evaluation and assessment.
For each topic area, we reviewed: peer-reviewed literature and national reports; emerging federal
rules, regulations, and funding opportunities; state models and innovations; and community and
local programs and policies. Findings on progress, opportunities, and challenges identified
through our review were synthesized with information and perspectives obtained through a series
of key informant interviews with numerous thought leaders, experts, and community advocates in
the field.
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III. Implementation Progress
This section describes the implementation progress, opportunities, challenges, and road ahead for
19 provisions in the ACA critical to advancing racial and ethnic health equity. These provisions are
discussed in context of the aforementioned five topic areas.
A. Increasing Supply and Diversity in the Health Professions
Despite changing population dynamics, many racial and ethnic groups (e.g., African Americans,
Hispanics/Latinos, and Native Americans) remain underrepresented in the health professions.
The Institute of Medicine’s seminal report, In the Nation’s Compelling Interest: Ensuring Diversity
in the Health Care Workforce, sought to bring attention to this important issue, underscoring that
“increasing racial and ethnic diversity among health professionals is important because evidence
indicates that diversity is associated with improved access to care for racial and ethnic minority
patients, greater patient choice and satisfaction, and better educational experiences for health
professions students, among many other benefits.” Here we summarize the ACA’s provisions and
progress in addressing diversity across a range of health professions.
•
Physicians and Physician Assistants. The ACA reauthorizes the Primary Care Training
and Enhancement Program to support training in family medicine, general internal
medicine, and general pediatrics. The law authorizes $125 million in funding for FY 2010,
along with such sums as necessary for FYs 2011-2014, of which 15% is designated for the
Physician Assistant Training Program. Funded for more than the ACA had intended, these
programs are training an estimated 889 new physicians and 700 new physician assistants
by 2015. A review of funded programs indicates that at least 40% explicitly acknowledge
that they will expand their programs to include more racially and ethnically diverse
trainees or address cultural competency. The large majority of these programs have
created opportunities for primary care residents to serve in underserved communities,
either through their own institution or in partnership with health centers, community
hospitals, and other community-based health care settings. However, there is widespread
acknowledgement that the expansion funded through this provision is only a small
portion of what will be needed to adequately meet the nation’s primary care workforce
needs.
•
Dentists. A new grants program for training in general, pediatric, and public health
dentistry is established by the ACA. Among other criteria, priority for grant awards is
given to entities that have a record of training individuals from underrepresented and
disadvantaged groups that provide training in “cultural competency and health literacy,”
and have a record of placing trained professionals in settings experiencing health
disparities. While the ACA explicitly authorized $30 million in FY 2010 and such sums as
necessary for FYs 2011-2014, a total of $71 million has been funded between FYs 2010-2013,
with another $21 million requested for FY 2014. A review of funded programs reveals that
many aim to address health disparities by merging didactic learning in public health
dentistry with training in community settings, such as health centers, to heighten
practical knowledge and application of cultural competency and health literacy principles.
•
Nurses. The ACA modifies the original Nursing Workforce Diversity Program “to include
advanced education preparation, stipends for diploma or associate degree nurses to enter
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a bridge or degree completion program, and student scholarships or stipends for
accelerated nursing degree program students.” In 2011, HHS awarded $3.6 million to 11
Nursing Workforce Diversity grantees. A review of grantee programs reveals that, by their
very intent, all incorporate a focus on diverse, underrepresented, and disadvantaged
nursing students. This goal is achieved through activities such as pipeline programs,
improving nursing retention in college, financial stipends to increase graduation rates,
and enhancing existing cultural competency and cultural awareness strategies. In 2011,
HHS also awarded other grants for enhancing the nursing workforce generally, some of
which also address diversity and equity. For example, roughly 40% Nurse Education,
Practice, Quality and Retention program grantees explicitly mention that they address
health professions diversity or cultural competency.
•
Mental Health Providers. The ACA authorizes grant funding to academic institutions or
professional training programs to recruit students into education programs for social work
and psychology, programs that are developing or expanding internships or field placement
opportunities in child and adolescent mental health, and training programs for
paraprofessional child and adolescent mental health workers. Diversity in race, ethnicity,
culture, geography, language, religion, socioeconomic status, gender, or sexual orientation
is among criteria for eligibility for a grant award. In September 2012, HHS awarded nearly
$10 million to 24 graduate social work and psychology academic institutions. At least 10
grantees cite that they explicitly address racial and ethnic diversity. These grantees
describe a number of strategies to enhance training for their students and interns with a
specific focus on recognizing and addressing mental health needs of individuals in
professional shortage areas.
•
Long Term Care Providers. The law funds a novel program that provides grants to higher
education institutions for the training of direct care workers. While there is not explicit
language related to diverse populations, this provision holds promise for advancing the
health of such communities as a significant percentage of the direct care workforce is
made up racially and ethnically diverse individuals. No funding has been appropriated for
this provision, to date. Nonetheless, the development of the direct care workforce and
related priorities are being addressed under other funded provisions of the ACA. For
example, Section 5507 established demonstration projects for six states which are
currently being implemented.
•
Community Health Workers. The ACA establishes a novel grants program to promote
positive health behaviors and outcomes for populations in medically underserved
communities through the use of Community Health Workers (CHW). This provision has
not been funded, although opportunities and priorities for community health workers
have been funded through other sections of the ACA, such as Community Transformation
Grants (Sec 4201). Many community health worker initiatives being implemented with
support beyond the ACA serve as models and best practice examples for successful
strategies to reach, engage, and serve diverse patients. A common characteristic of these
programs which is essential to caring for underserved communities is a close connection
to the target population (whether it be through shared race, ethnicity, language or other
experiences). There are several challenges that continue to undermine the CHW
workforce. These include, for example, limited funding, uncertainty around sustainability
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of funded programs, lack of reimbursement for services provided by CHWs, and limited
training standards or certification, among others.
B. Workforce Support for the Health Care Safety Net
While the large majority of workforce provisions discussed in this report have implications for the
health care safety net, there are at least three that explicitly target programs within public
hospitals, community health centers, and other safety net settings. In this section, we discuss the
implementation status, progress, and challenges related to these provisions.
•
National Health Service Corps. The ACA reauthorizes the National Health Service Corps
(NHSC) as well as increases the amount of funding for the program by authorizing new
dedicated funding in the amount of $1.5 billion for FYs 2011-2015. Through funding from
the ACA, the NHSC has grown approximately three times, training a growing proportion
of underrepresented minorities and expanding care to underserved communities. Based
on self-reported data by nearly 10,000 NHSC clinicians currently providing care, 13% are
African American, 10% are Hispanic, 7% are Asian or Pacific Islander, and 2% are
American Indian or Alaska Native. And in FY 2012, African American and Hispanic
physicians represented 17% and 16% of the NHSC, respectively, nearly three times their
representation in the national physician workforce (6.3% and 5.5%, respectively). And
more recently, of the nearly 1,000 NHSC scholars in the pipeline, more than half are
minorities (26% Hispanic, 19% African American, 12% Asian or Pacific Islander, and 2%
American Indian or Alaska Native).
•
Graduate Medical Education. The law authorizes, beginning July 1, 2011, the conversion
of unfilled hospital residency positions under the Graduate Medical Education (GME)
program to slots for primary care physicians, giving preference for redistributing slots to
states with a low resident physician-to-population ratio or with large numbers of people
living in primary care health professional shortage areas. In August 2011, excess slots were
redirected to 58 hospitals, 24 of which are located in areas where over half the population
is Non-White.
•
Area Health Education Center. The law authorizes $125 million for each FY 2010-2014 for
grants to Area Health Education Centers (AHECs) to support community-based training
and education. Awards are available for both the development of new health care
workforce educational programs as well as to continue or improve upon existing AHECs.
Despite being recognized as the only national program to recruit and support diverse and
disadvantaged students throughout their health careers pathway, the AHEC program
received less than one-fourth of the funding authorized under the ACA over the past four
years. This poses significant challenges for a program that is key to fostering a diverse
health care workforce.
C. Cultural Competency Education and Training
There is considerable evidence that cultural competency training improves intermediate
outcomes such as knowledge, attitudes, and skills of health professionals along with patientprovider interactions and patient satisfaction. Less evidence exists on its link to health outcomes.
Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come
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together in a system, agency, or among professionals that enables effective work in cross-cultural
situations. As summarized below, three provisions in the ACA explicitly seek to support and
advance cultural competency in health care.
•
Cultural Competency in Pain Care. The ACA authorizes research, treatment, and
education to further enhance and improve pain care management. Specifically, the ACA
charges NIH to expand its aggressive research through the Pain Consortium, and it also
authorizes HRSA to establish a new grants program for training in pain care. An explicit
requirement of this program is that grantees include information and education on
cultural, linguistic, literacy, geographic, and other barriers to pain care in underserved
populations. While the HRSA program has not received funding, the Pain Consortium has
made progress as evidenced by its meetings and a report released in 2011, Relieving Pain in
America: A Blueprint for Transforming Prevention, Care, Education, and Research. The
report highlights several aspects of racial and ethnic disparities in pain care. The report
also explicitly cites that “enhanced continuing education and training are needed for
health care professionals to address gaps in knowledge and competencies related to pain
assessment and management, cultural attitudes about pain.”
•
Cultural Competency in Geriatric and Long Term Care. The law authorizes grants for
new demonstration projects to develop core training competencies and certification
programs for personal or home care aides. In September 2010, HRSA awarded grants to six
states (Massachusetts, California, Iowa, Michigan, North Carolina, and Maine) under the
Personal and Home Care Aide State Training (PHCAST) Grant Program of the ACA.
Grants aim to strengthen the direct care workforce by defining core competencies for
direct care workers and supporting training development to further improve the
standardization of such competencies. In order to target a diverse population during
recruitment, states are also partnering with community colleges, current employers of
direct care workers as well as workforce investment boards. All states appear to have made
progress toward addressing the required competency of “understanding diversity and
cultural competence.”
•
Model Cultural Competency Curricula. The ACA authorizes a grants program for the
purpose of the development, evaluation, and dissemination of research, demonstration
projects, and model curricula for cultural competency, prevention, public health
proficiency, reducing health disparities and aptitude for working with individuals with
disabilities. As of this writing, this provision has not received funding under the ACA.
However, this is an important priority for advancing the field of cultural competence.
D. Health Workforce Evaluation and Assessment
As the ACA’s coverage expansions and novel practice models are implemented, it is critical to
gather and learn from concrete workforce data and analysis to make informed and accurate
decisions about healthcare workforce needs and challenges, including those related to serving a
growing diverse patient population. In this section, we highlight two important provisions that
support improved mechanisms to evaluate and assess workforce needs.
•
National Health Care Workforce Commission. The ACA authorizes the establishment
of a new entity to coordinate healthcare workforce activities across federal agencies,
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evaluate workforce demands and education needs, identify and propose solutions to
current and future workforce challenges, and support novel programs to improve health
care professions education. While a 15-member Commission was announced in September
2010, Congress has not appropriated funding for this provision as of this writing.
•
State Health Care Workforce Development Grants. The ACA establishes a
competitive, HRSA-administered grant program under which 25 states were awarded
planning grants and 1 state received an implementation grant. In FY 2010, $6 million was
awarded from the Prevention and Public Health Fund to implement these grants. Such
sums as necessary were authorized for the following years and no further funding has
been appropriated. The overall goal described by grantees is to gather data and
information for planning activities to create a comprehensive plan to address health care
workforce shortages. Of 25 grantees, 8 outline explicit goals with a focus on immigrants,
diverse, or vulnerable populations, or to reduce health disparities. Virginia, the single
implementation grantee, describes goals related to cultural competence.
E. Health Care Workforce Investment in Academic Settings
Initiatives to improve minority enrollment implemented at the college and graduate levels of
education have shown promising results in increasing diversity in the health professions. The
ACA includes at least three provisions intended to support and strengthen these and other
programs at academic settings to ensure the health care workforce is more reflective of the
nation’s diverse patients and families.
•
Historically Black Colleges and Universities (HBCUs) & Minority-Serving
Institutions. The health care reform law amends the Higher Education Act by extending
the authority to award funding to HBCUs and other minority-serving institutions through
2019. Mandatory funding for FYs 2008-2019 is available in the amount of $255 million.
Questions remain as to whether the increased funding from the ACA is sufficient to
alleviate concerns around sustainability of minority-serving institutions. Distributed
among more than 100 universities and colleges, the annual funding authorized through
the law is relatively modest. Since HBCUs are critical for the educational achievements of
many African Americans from college through post-graduate studies, they are an
important component of ensuring a diverse healthcare workforce. Despite this promise,
however, recent studies suggest that HBCUs are not playing a large enough role in
educating African American health professionals. While HBCUs saw a modest increase in
the graduation of African American practitioners between 2000 and 2008, this increase
did not keep pace with growing need or with graduation of African Americans from
comparable programs at White institutions.
•
Centers of Excellence (COEs). The ACA authorizes $50 million for each FY 2010-2015 for
COEs, a federal program to enhance training opportunities for minority students and
faculty administered by HRSA and originally authorized under Title VII of the Public
Health Service Act. Over the past four years, COEs have received less than half of the
funding authorized by the ACA. A review of grantees between FYs 2010–2012 reveals that
18 explicitly target Hispanics or Latinos; 4 target African Americans; 5 target Native
Americans; and 12 target minorities in general (i.e., more than one racial/ethnic group). A
programmatic review revealed that several institutions are adopting common strategies
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and practices to train and prepare a diverse health care workforce. For example, to recruit,
train, and retain minority students, many programs are increasing the pool of qualified
applicants through pipeline and outreach programs designed to inspire students in diverse
settings early on in their education to pursue health professions careers. Several programs
are also offering cultural competency training through diverse clinical experiences in
community health settings and are also committed to increasing diversity among faculty
members.
•
Health Care Professions Training for Diversity. The law reauthorizes two key
programs for health care professions training among underrepresented minorities. First,
the ACA reauthorizes the Scholarships for Disadvantaged Students (SDS) program,
allocating $51 million in FY 2010, and such sums as necessary for FYs 2011-2014. This
program funds scholarships for disadvantaged students who commit to working in
medically underserved areas. In FY 2010, this program received $49 million, with
appropriations declining each year to $44 million in FY 2013. Secondly, the ACA
reauthorizes the Health Careers Opportunity Program (HCOP), allocating $60 million in
FY 2010 with such sums as necessary for FYs 2011-2014. The goal of HCOP is to support
individuals from disadvantaged backgrounds in entering and graduating from health
professions programs. In FY 2010, HCOP received just over one-third of authorized
funding (i.e., $22 million), with funding declining each year to just $14 million in FY 2013.
Despite studies that show the benefits of tailored enrollment and retention programs for
minority students, programs such as SDS and HCOP have been declining in support over
the years. Though the ACA showed significant promise in changing this trend by
authorizing the highest level of funding since 2005 for HCOP, for example, actual
appropriations were far less.
IV. Renewed Opportunities and Remaining Challenges for the Health Care
Workforce
Among other equity objectives, the ACA is committed to supporting and expanding the nation’s
health care workforce, including enhancing efforts to ensure providers are more representative of
the populations they serve, are located in underserved areas, and possess skills to provide
culturally and linguistically competent care. The ACA reauthorizes and expands a number of
programs originally authorized under Titles VII and VIII of the Public Health Service Act, giving
preference to, in many cases, underrepresented minorities and services provided in traditionally
underserved, diverse communities. It also authorizes a series of novel workforce initiatives which
offer the potential for further strengthening the health care workforce. Despite this momentum,
these efforts may not be sufficient to match increases in demand expected from the growth in
newly insured populations following the operation of health insurance exchanges and state
expansions in Medicaid. Thus, while over 19 million racially and ethnically diverse enrollees may
be eligible to become newly insured through the exchanges and Medicaid, lack of funding may
jeopardize, if not prevent, programs from achieving their goals. Three prominent concerns and
challenges exist to addressing workforce needs and diversity in an era of reform.
Continued Workforce Shortages. Significant shortages are expected across the range of health
professions—including doctors, nurses, dentists, and others—potentially posing “one of the
biggest threats” to the overall success of health care reform. The implementation of the ACA is
projected to increase the number of insured by 30 million, over half of whom will be racially and
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ethnically diverse individuals. This increase, along with an aging population and general
population growth, will boost the demand for medical services. In particular, steep increases in
demand for primary care are expected, along with an insufficient supply of providers to match
this increase in many regions of the country.
Limited and Declining Funding for Workforce Diversity Initiatives. Funding continues to be
an overarching challenge for supporting the health care workforce, generally, and particularly to
advance diversity and cultural competency. Among the 19 provisions reviewed in this report, the
six explicitly focused on enhancing primary care capacity—such as increasing the number of
primary care physicians, physician assistants, and the National Health Service Corps—have seen
the greatest level of federal support and commitment. The other nearly dozen provisions have
either been severely under-funded or have not received any funding to date. Among critical
programs supported in intent by the ACA, but with declining funding are the Centers for
Excellence, Scholarships for Disadvantaged Students, and the Health Careers Opportunity
program. Minority-serving institutions have also only modestly been supported by the ACA
despite the fact that they train a large proportion of minorities in the health professions and
generally do not differ in performance of training from other academic institutions.
Reluctance to Pursue Diversity and Cultural Competency as a Priority. Despite considerable
progress in addressing health disparities, promoting a diverse and culturally competent health
care workforce largely remains a “tough sell”—politically, institutionally, and within the health
care system. Reasons are varied and range from diversity and cultural competency not being a
priority to limited data and evidence linking such efforts to better outcomes, and a narrow
mindset on what diversity essentially means or encompasses. As one key informant noted,
“…things that are not a priority, like cultural competency, get put on at the very end…it’s not in
the ‘urgent’ category.” Some suggested that the reason cultural competency efforts have not
made it to the forefront of priorities is that they are still trying to figure out how to implement
broader provisions around delivery and payment reform: “It’s evident that no one understands
what is happening broadly. There is no discussion of diversity and cultural competency because
they’re still struggling with what broader change means.”
V. Moving Forward: Ensuring Diversity and Cultural Competency in the
Health Care Workforce
We identify at least six areas of priority in working to ensure the nation’s workforce is adequate in
supply and skill to serve a growing insured, racially and ethnically diverse, and aging population.
These priority areas build on common themes we identified through a synthesis of research,
policy review, grant opportunities, grantee programs, and interviews around the implementation
of the ACA, but also reflect longstanding challenges, needs and roles.
Expanding scope of practice. While the expansion of insurance coverage created through the
ACA will open doors to care for millions, great concern remains around the capacity of health
care settings and systems to meet the demand for services, especially for diverse, low-income, and
other vulnerable populations. As health professionals’ capacity is at the center of this concern,
provider organizations and policymakers are seeking ways to expand the pool of qualified
practitioners. With the uncertainty around support for many of the ACA’s workforce diversity
provisions, expanding scope of practice may offer new opportunities for improving provider
capacity and diversity and, in turn improving access for historically underserved populations.
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Scope of practice laws establish the legal framework by which medical services are delivered.
These laws vary by state. Many states and advocates are looking to scope of practice laws to
reassess the role that providers such as advanced practice nurses and physician assistants can play
to fill shortages in primary care physicians. Emerging studies show that these providers can
generally provide 80% of the care that primary care physicians currently provide and that their
care is “as safe and effective as care provided by doctors.”
Encouraging interdisciplinary team-based care. Many of the ACA’s provisions are intended to
promote patient-centered care, care coordination, and recognition of health-related
circumstances beyond the clinical encounter that may significantly affect treatment adherence
and outcomes. Culture and language-specific concerns, community characteristics such as child
care, safety, and access to healthy foods, all contribute to the ability to deliver services efficiently
and effectively. To integrate these and other priorities into treatment plans, many health care
providers are testing and implementing new models of care delivery. One such model is the
interdisciplinary team-based approach which involves health professionals beyond physicians—
including for example, nurses, social workers, mental health professionals, and others—to
coordinate care and other patient services. There are a range of team-based approaches to care,
and many of which are part of the Patient-Centered Medical Home model of care. Community
health workers, in particular, are seen as important players in team-based care and studies show
they contribute to improved access to care, culturally competent chronic disease management,
and cost-effectiveness. Team-based approaches which utilize social workers and nursepractitioners, working alongside primary care physicians have also shown promise particularly in
the care of diverse and vulnerable geriatric populations.
Integrating the Enhanced CLAS Standards into Workforce Programs. The release of the
enhanced National Standards on Culturally and Linguistically Appropriate Services (CLAS) in 2013
comes at a pivotal time in efforts to redress longstanding disparities and advance health equity.
The CLAS standards are intended to serve as a set of guiding principles for health care
organizations in serving diverse populations and were developed, in their original form in 2000, to
direct cultural and linguistic competency in health care. The CLAS standards align closely with
the ACA’s provisions around workforce and systems capacity including developing a culturally
competent workforce, enhancing diversity, and integrating equity priorities into leadership and
governance. Examples of the synergy between the ACA and CLAS standards include provisions
around workforce support and diversity—e.g., tailoring CLAS Standards 1 and 4 to inform and
guide primary care providers, nurses, dental and mental health providers, pain care providers and
community health workers on providing culturally and linguistically appropriate care. Standard 3
addresses recruitment of a diverse workforce, an essential goal to achieving health equity that is
also underscored in the ACA. Standard 13 describes community partnerships to enhance cultural
and linguistic appropriateness of care, a collaboration that many ACA grantees are pursuing in
training and education programs. These standards also offer clear opportunity to incorporate
elements of culture and language into workforce evaluation, impact, and assessment of ACAfunded programs.
Evaluating health care workforce diversity needs, capacity, and outcomes. With the
numbers of insured projected to grow exponentially as the ACA marketplaces and state Medicaid
expansions roll out, understanding community, state, and national workforce capacity needs—
including creating a more diverse health care workforce—will be especially critical for meeting
new demands for services, for reaching historically underserved populations, and ultimately, for
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eliminating disparities in access to and quality of care. To this end, evaluating national, state and
local strategies to improve workforce diversity across the country as well as those within various
disciplines offers the opportunity to determine progress in advancing related goals around:
meeting service needs and capacity; recruitment and retention of a diverse workforce; and the
effectiveness of cultural competency training and education.
Enhancing Support for Health Professions Schools and Initiatives Committed to
Diversity and Equity. Medical and health professions schools, urban and minorityserving universities, community colleges, and health professional societies stand to play an
important and central role in attracting and training a diverse health care workforce to
meet growing need and demand expected in 2014. Several institutions—such as the
Association of American Medical Colleges (AAMC) and urban universities— are beginning
to take a leadership role in addressing this priority, while others do not have the support
that could reinforce their important role—such as HBCUs and other minority-serving
institutions. In all, there is a need to garner more widespread awareness and support for
institutions committed to diversity and equity, especially given federal funding through the
ACA and otherwise for many efforts is significantly compromised.
Leveraging Resources Provided through the ACA with Philanthropic Support. Given the
many financial and ideological challenges to advancing health equity across states and
communities, advancing workforce diversity and cultural competency will require supplemental
support from other funding avenues—both federally and beyond, including the private sector.
Well-funded programs, particularly those with mandatory funding in the ACA, may offer some
opportunity. For example, the Patient-Centered Outcomes Research Institute authorized through
2019, may offer an avenue to test the efficacy of cultural competency or other specific workforce
diversity initiatives. The private sector may also fill gaps in support for such efforts. In fact, in
many communities, national, state, and local philanthropies and foundations are beginning to fill
an important void to support the health care workforce, particularly where sufficient support
from the ACA and other federal sources has not occurred.
VI. Conclusion
The ACA’s numerous provisions reaffirm many existing workforce efforts and intend to advance
new initiatives—although not funded or underfunded in some cases—such as creating a national
workforce commission, promoting cultural competence education, and supporting
underrepresented minorities in health professions. At its core, this emphasis seems
to acknowledge the formidable challenges that lie ahead in redressing limitations and disparities
of the past affecting access to timely, high quality health care, and assuring that the intent of the
new law to truly enfranchise new populations is fulfilled. The related demand for a high quality,
diverse workforce will only grow, but will require significant resources and political will. What
remains much less clear in moving into the fifth year of ACA implementation is whether the
resources and political will to support a broad spectrum of critical programs and actions will be
sufficient to meet service goals and people’s needs.
xv
I. Introduction
Enhancing racial and ethnic diversity in the health professions is vital to advancing and achieving
an accessible and equitable health care system. Despite recent efforts, racial and ethnic health
disparities in access, quality, and outcomes persist and remain entrenched in health care. In fact,
four out of ten African Americans and Hispanics/Latinos continue to receive worse care than
Whites on a set of quality measures.1 Hispanics/Latinos also face worse access to care than Whites
for nearly two-thirds of access measures.2 While a complex set of factors contribute to these
disparities, well-established research cites the lack of diversity in the health care workforce as
being a major contributing factor.
Growing evidence suggests that workforce diversity—and related cultural competency efforts—
are associated with higher patient satisfaction, improved patient-provider communication, and
better treatment adherence.3,4 However, much work still needs to be done to achieve the goal. As
recent data confirm, the composition of the health care workforce is not reflective of the changing
and diversifying population dynamics.5 Whereas racially and ethnically diverse communities
comprise one-third of the U.S. population, they only account for one-fifth of physicians and
nearly 17% of registered nurses.6,7 Particularly underrepresented in medical, nursing, and other
health professions are African Americans and Hispanics/Latinos. For example, while over 15% of
the population is Hispanic/Latino, only 5% of physicians and 4% of registered nurses are
Hispanic/Latino.8 Similarly, African Americans comprise about 12% of the population, but only
6% of physicians and 5% of registered nurses.9
Studies over the years have shown that racially and ethnically diverse practitioners are more likely
to practice in medically underserved areas, and to disproportionately serve low-income,
uninsured, and underinsured patients from diverse racial and ethnic heritage.10 As summarized in
a recent publication:
Diversity is a critical part of the mission of health care and the national challenge of
preparing our nation’s future workforce. America’s success in improving health status and
advancing the health sciences is wholly dependent on the contributions of people from a
myriad of diverse backgrounds and cultures, including Latinos, Native Americans, African
Americans, European Americans and Asian Americans. The lack of diversity is a key barrier
to ensuring a culturally competent health care system at the provider, organizational, and
system levels. It diminishes our nation’s capacity to eliminate racial and ethnic health
11
disparities and compromises our national capacity to advance the health sciences.
Racially and ethnically diverse populations face clear and persistent barriers to entering and
succeeding in the health professions. Students of color report higher rates of financial setbacks,
racism, lack of professional role models and diverse faculty, and fewer educational resources,12,13
contributing to greater challenges in embarking on and completing the educational pathways
required for a career in health care.
Federal efforts have sought to expand, diversify, and improve the distribution of the health care
workforce through the alignment of funding priorities with the nation’s health care needs. Title
VII and Title VIII programs, authorized by the Public Health Services Act, for example, encourage
health professionals to care for those in medically underserved communities, provide grants to
health professions schools and institutions, and support health professions students with
scholarships and loans.14 While these programs generally have succeeded in enhancing cultural
and geographic diversity, including improving the number of underrepresented minority
graduates among health professionals,15 in recent years they have witnessed declining support and
funding challenges. For example, federal funding for programs such as the Centers of Excellence
(COE) and the Health Careers Opportunities Program (HCOP), which both include explicit goals
to recruit and retain minority students, was reduced significantly in 2006 resulting in dramatic
challenges to their sustainability. Since 2006, funding has gradually increased each year, but has
not yet reached its prior levels.16
With the advent of health care reform, renewed opportunities for enhancing and expanding
existing programs as well as explicitly addressing workforce diversity have emerged. The ACA
includes numerous provisions that reauthorize various programs under Titles VII and VIII of the
Public Health Service Act as well as authorize several new initiatives to support a diverse and
culturally competent workforce. Understanding the status and progress of such provisions in
terms of support, funding, and implementation is critical to assuring this priority is fully realized
to advance and achieve health equity.
Purpose and Rationale
The purpose of this report is to provide a point-in-time status and progress update on the
implementation of the ACA’s provisions for supporting a more racially and ethnically diverse, as
well as culturally and linguistically competent health care workforce. As such, it describes the
opportunities presented by the new law, along with challenges, lessons learned and potential next
steps for successfully implementing major provisions of the law critical for advancing diversity
and equity in health care. Embedded within this report are emerging programs, best practices,
and resources that address workforce diversity, cultural competency training, and related efforts.
We identified and monitored 19 provisions which explicitly mention or have significant relevance
for advancing racial and ethnic equity and cultural competency in the health professions.
Organization of Report
This report is organized into the following four sections:
I.
Introduction: This section provides an overview of the goals, objectives, target
audience, and value and use of this report. It also describes the Affordable Care Act &
Racial and Ethnic Health Equity Series in greater depth.
II.
Methodology: The framework and design is discussed in this section, along with
specific activities that were undertaken in developing this report.
III.
Implementation Progress: This section describes the legislative context,
implementation progress, emerging progress and models, and challenges and next
steps for the 19 provisions, organized by five key priorities:
A. Increasing supply and diversity in the health professions;
B. Workforce support for the health care safety net;
C. Cultural competency education and training;
D. Health care workforce investment in academic settings; and
E. Health workforce evaluation and assessment.
17
IV.
Renewed Opportunities, Remaining Challenges for the Health Care Workforce:
Discussed in this section are the common and distinct themes that emerged on
implementation progress and opportunities, along with challenges that must be
considered to ensure a culturally and linguistically diverse and competent health care
workforce.
V.
Moving Forward: The report is rounded out with a discussion of recommended next
steps for ensuring that diversity, equity, and cultural competency are integrated and
reflected in the health care workforce—both generally, and as envisioned by the ACA.
Given that health care reform is rapidly evolving, with new information and policies emerging
almost daily, we reiterate that this report offers a point-in-time snapshot of information,
perspectives, and resources that were available during the time this project was undertaken.
18
Affordable Care Act & Racial and Ethnic Health Equity Series
Series Background and Context
We have been monitoring and analyzing the evolution of health care reform and its implications for
reducing disparities and improving equity since shortly after the inauguration of President Obama in
2009. With support from the Joint Center for Political and Economic Studies in Washington, D.C., the
project team tracked major House and Senate health care reform bills, identifying and reviewing
dozens of provisions with implications for racially and ethnically diverse communities. A series of
reports and issue briefs were released, providing a resource for community advocates, researchers, and
policymakers seeking to understand and compare the significance and implications of these
provisions. Following the enactment of the ACA, a major, comprehensive report--entitled Patient
Protection and Affordable Care Act: Implications for Racially and Ethnically Diverse Populations17--was
developed and released in July 2010 describing nearly six dozen provisions in the law core to advancing
health equity. The report covered ACA’s opportunities and new requirements related to health
insurance, the safety net and other points of health care access, workforce diversity and cultural
competence, health disparities research, prevention and public health, and quality improvement.
Series Purpose and Objectives
The overall purpose of the Affordable Care Act and Health Equity Series is to provide an informative,
timely, user-friendly set of reports as a resource for use by health care organizations, communitybased organizations, health advocates, public health professionals, policymakers, and others seeking
to implement or take advantage of the ACA to reduce racial and ethnic health disparities, advance
equity, and promote healthy communities. The Series is funded by W. K. Kellogg Foundation and The
California Endowment. The Series is intended to:
•
Provide a point-in-time snapshot of implementation progress—or lack thereof—of over 60
provisions in the ACA with implications for advancing racial and ethnic health equity,
detailing their funding status, actions to date, and how they are moving forward;
•
Showcase concrete opportunities presented by the ACA for advancing racial and ethnic health
equity, such as funding, collaborative efforts, and innovation that organizations can take
advantage of;
•
Highlight any threats, challenges, or adverse implications of the law for diverse communities
to inform related advocacy and policy efforts; and
•
Provide practical guidance and recommendations for audiences working to implement these
provisions at the federal, state, and local levels, by documenting model programs, best
practices, and lessons learned.
19
Series Design and Methodology
The project team utilized a multi-pronged, qualitative approach to monitor and assess the
implementation progress, opportunities, and challenges of roughly 60 provisions in the ACA across
five topic areas:
• Health insurance exchanges;
• Health care safety net;
• Workforce support and diversity;
• Data, research and quality; and
• Public health and prevention.
For each topic area, the project team conducted a comprehensive review of literature and reports,
along with an in-depth assessment of the legislation, emerging federal rules, regulations, and funding
opportunities; state models and innovations; and community and local programs and policies. To
complement research, programs, and policies identified through this review, the team conducted
telephone-based interviews with nearly 70 national experts and advocates, federal and state
government representatives, health care providers, health plans, community organizations, and
researchers in the field. A full list of participants and contributors can be found in Appendix A.
Interview questions were tailored to the sectors that respondents presented (e.g., state agencies,
hospitals, health plans, community organizations, and others) and were intended to fill important
information gaps as well as reinforce themes around emerging progress, opportunities, challenges, and
actions not otherwise discussed in written sources. Findings from the literature review, policy
analyses, and interviews were synthesized into five topic-specific reports.
Given each report is topic-specific and part of a larger Series, every attempt was made to crossreference subtopics across the Series. For example, support for the National Health Services Corps is
highlighted under the “Workforce” topic, although it has direct relevance for the “Safety Net” report.
Organizing and cross-referencing the reports in this manner was important to streamlining the large
amounts of information and ensuring the reports remained user-friendly.
Series Audience and Use
With the latest policy updates and research, complemented by voices and perspectives from a range of
sectors and players in the field, the goal of this Series is to offer a unique resource and reference guide
on the implementation status of the ACA’s diversity and equity provisions along with emerging
opportunities and actions to reduce disparities. However, given the health care arena is rapidly
evolving and expanding, with new guidance, policies, and actions emerging almost daily at all levels,
this Series offers a point-in-time snapshot of information, perspectives, and resources that were readily
available and accessible during the time this project was undertaken.
Reports issued as part of this Series are intended for broad audiences and use. For example, federal
government agencies may utilize information on best practices, resources, and concerns in the field to
inform the development of ACA-related rules and regulations addressing equity, diversity, language,
and culture. Nonprofit and community organizations may look to the reports for concrete
opportunities for involvement, collaboration, or funding. Health care providers, public health
agencies, state exchanges, and health plans may draw on models, best practices, and resources to
implement or enhance their own efforts to tailor and ensure racial and ethnic equity and diversity are
core to their plans and actions. Advocacy organizations may use data or findings to advocate for
appropriations, funding, or support for a variety of equity priorities supported by the ACA.
20
II. Methodology
We utilized a multi-pronged, qualitative approach to monitor and assess the implementation
progress, opportunities and challenges of the Affordable Care Act’s (ACA) workforce diversity and
cultural competency provisions. In this section, we provide a brief overview of our methodology.
Literature and Policy Review. We conducted a comprehensive review of literature on the health
care workforce as well as issues of diversity and cultural competency, generally and in context of
the ACA. This was complemented by a review of emerging federal regulations, guidance, and
funding opportunities for implementing each of the 19 workforce related provisions. Given the
constantly evolving nature of the field, information and research included in this report is current
as of July 2013. In addition, we conducted an extensive review of research and articles on state
activities along with programs and models emerging in academic, safety-net, and other health
care settings, with the intent of identifying information and guidance that can inform what is
required to effectively implement the 19 provisions.
Key Informant Interviews. To obtain the most recent information and perspectives from
individuals currently working on these issues, we interviewed state and county health officials,
hospital and health center representatives, academic researchers, and representatives from several
community and advocacy organizations. We gathered names and contact information for people
to interview from various sources including meetings we attended, reports we reviewed, and
references from other people we spoke to. Following are questions covered through the
interviews:
• How are states and organizations concertedly addressing workforce needs through
the ACA, and are there broader state or local efforts to leverage these actions?
•
What opportunities in the ACA are states and organizations taking advantage of to
enhance their health care workforce? How are diversity, equity, and culturally
competency being addressed through these vehicles?
•
Are there any specific programs or other efforts that states and organizations are
participating in to improve workforce diversity and/or cultural competency that are
occurring in parallel or in context of the ACA’s objectives?
•
What challenges are states and organizations facing in taking advantage of workforce
diversity and cultural competency opportunities under the ACA?
•
What are thoughts moving forward, or recommendations, for ensuring diversity and
cultural competency remain integral to workforce enhancement efforts?
Given the range of roles, expertise, and perspectives represented by key informants, not all
questions were posed to each informant. Rather, those that applied most directly with an
individual’s area of expertise and knowledge were asked.
Synthesis and Analysis. Based on common themes and issues that affect the major players in the
health care workforce, the 19 provisions were organized into five themes as follows:
A. Increasing Supply and Diversity of Health Care Professionals
• Section 5203. Health care workforce loan repayment programs
• Section 5301. Training for primary care physicians and physician assistants
21
•
•
•
•
•
•
Section 5302. Training opportunities for direct care workers
Section 5303. Training in general, pediatric, and public health dentistry
Section 5306. Mental and behavioral health education and training grants
Section 5309. Nurse education, practice, and retention grants
Section 5404. Workforce diversity grants
Section 5313. Grants to promote the community health workforce
B. Workforce Support for the Health Care Safety Net
• Section 5207. Funding for National Health Service Corps
• Section 5403. Interdisciplinary, community-based linkages
• Section 5503. Distribution of additional residency positions
C. Cultural Competency Education and Training
• Section 4305. Advancing research and treatment for pain care management
• Section 5307. Cultural competency, prevention, and public health
• Section 5507. Demonstration s to address health professions workforce needs
D. Health Workforce Evaluation and Assessment
• Section 5101. National health care workforce commission
• Section 5102. State health care workforce development grants
E. Health Care Workforce Investment in Academic Settings
• Section 2103. Investment in minority-serving institutions
• Section 5401. Centers of excellence
• Section 5402. Health care professionals training for diversity
For each provision, the project team compiled research, latest policy updates, regulations and
funding opportunities and announcements, along with synthesized key informant interview
findings to address the following areas of inquiry:
•
Legislative context of each provision, both as authorized by the ACA and also by
any prior legislation.
•
Implementation status and progress as documented in the Federal Register, peerreviewed literature, reports, funding announcements, grantee reports, and related.
•
Emerging models and programs, including those established prior to the ACA that
can inform current implementation, as well as those that have emerged post-ACA.
•
Challenges and next steps to realizing the objectives of the provision.
Information from the interviews can be found throughout the sections of the report, and
respondents were told that their responses would not be attributed or quoted without their
permission. Responses were not statistically analyzed and are not intended to be a representative
sample of states, hospitals, health centers, or other health care providers. Rather, this information
is qualitative in nature and serves to fill any knowledge gaps, as well as add further depth,
dimension, and perspective to further inform the implementation of the specific ACA provisions.
22
III. Implementation Progress
The ACA presents a range of opportunities for supporting and creating a more diverse and
culturally competent healthcare workforce. This section describes the implementation progress,
opportunities, challenges and road ahead for realizing the 19 provisions in the new law, organized
by the following themes:
•
•
•
•
•
Increasing the supply and diversity of health care professionals;
Workforce support for the health care safety net;
Cultural competency education and training;
Health workforce evaluation and assessment; and
Health care workforce investment in academic settings.
Appendix B provides an “At-A-Glance” summary of these provisions, along with their funding
allocations, implementation status, and progress.
A. Increasing Supply and Diversity of Health Care Professionals
Background
The racial and ethnic composition of the
United States is rapidly evolving. By 2050,
Non-White racial and ethnic groups will
constitute more than half the nation’s
population. 18 Hispanic and Asian
populations, in particular, are expected to
almost double between now and 2050
(Figure 1).19 Despite these changing
population dynamics, however, many
diverse population groups (e.g., African
Americans, Hispanics/Latinos, and Native
Americans) remain underrepresented in
the health professions. The Institute of
Medicine’s seminal report, In the Nation’s
Compelling Interest: Ensuring Diversity in
the Health Care Workforce, sought to
bring attention to this important issue,
underscoring that “increasing racial and
ethnic diversity among health
professionals is important because
evidence indicates that diversity is
associated with improved access to care
for racial and ethnic minority patients,
greater patient choice and satisfaction,
and better educational experiences for
health professions students, among many other benefits.”20
23
Figure 1
This underrepresentation is both broad and deep. Whereas African Americans comprise 12% of
the U.S. population, they account for approximately 6% of medical doctors, 5% of registered
nurses, 8% of physician assistants, and 3% of dentists (Tables 1 and 2). Similarly,
Hispanics/Latinos comprise over 15% of the population, but only 5% of medical doctors, nearly
4% of registered nurses, 8% of physician assistants, and 6% of dentists.
Table 1. Total U.S. Registered Nurses, Medical Doctors, and Physician Assistants
by Race and Ethnicity, 2007/2008
RNs* (2008)
MDs** (2008)
PAs*** (2007)
No.
%
No.
%
No
%
White
2,549,302
83.2%
353,311
75%
75,408
77.2%
Percentage
of U.S.
Population
65.6%
Black
165,352
5.4%
29,775
6.3%
7,606
7.8%
12.2%
Asian
169,454
5.5%
60,090
12.8%
5,382
5.5%
4.5%
Hispanic
109,387
3.6%
25,717
5.5%
8.053
8.2%
15.4%
AI/AN
18,099
0.6%
2,515
0.5%
470
0.5%
0.8%
*Source: 2008 National Sample Survey of Registered Nurses as cited in: The Registered Nurse Population, Findings from
the 2008 National Sample of Registered Nurses. September 2010. HHS/HRSA
**AAMC Data warehouse: Minority Physician Database, AMA_Masterfile_R,App_Bio_R,asof11/30/2009 as cited in:
Diversity in the Physician Workforce: Facts & Figures 2010, AAMC.
***U.S. Census Bureau as cited in: Xiaoxing, H., Ellen, C., & Mark, S. National trends in the United States of America
physician assistant workforce from 1980 to 2007. Human Resources for Health, 7.
Table 2. Total U.S. Dental Professionals by Race and Ethnicity, 2007
Dentists
Dental Hygienists
Dental Assistants
No.
%
No.
%
No
%
White
138,866
76.3%
137,795
88.9%
217,288
69.2%
Percentage
of U.S.
Population
65.6%
Black
637
3.5%
3,410
2.2%
20,410
6.5%
12.2%
Asian
235
12.9%
4,340
2.8%
14,758
4.7%
4.5%
Hispanic
116
6.4%
7,440
4.8%
55,892
17.8%
15.4%
Source: U.S. Census Bureau, American Community Survey, 2007 as cited in: National Healthcare Disparities Report, 2009,
Agency for Healthcare Research and Quality
Note: There are a total of 182,000 dentists, 155,000 dental hygienists, and 314,000 dental assistants. Data for American
Indians/Alaska Natives was not available.
For nearly 50 years, Titles VII and VIII of the Public Health Service Act have been working to
increase racial and ethnic diversity in the health care workforce and encourage health care
providers to practice in medically underserved areas.21,22,23 Both Titles VII and VIII were
established in response to a severe shortage of health care providers. Title VII, enacted in 1963,
was designed to “encourage health care workers to practice in underserved areas, increase the
number of primary care providers, increase the number of minority and disadvantaged students
enrolling in health care programs, and increase the number of faculty in health care education
and training programs.”24 Title VIII, established in 1964, was primarily aimed at training advanced
practice nurses and increasing the number of minority and disadvantaged students enrolling in
nursing programs.25
24
The federal Health Resources and Services Administration (HRSA) administers Titles VII and VIII
programs, and has been a major funder of health professions training, including programs geared
toward expanding diversity and increasing the number of providers from underrepresented
minorities. Over the years, these titles have been amended to provide grants to support
traineeships in other health professions. For example, in 1988, Title VIII was amended to
“authorize student loan repayment and scholarship programs to fund education and training for
public health nurses, registered nurses, nurse midwives, and other nurse specialties.”26
Outcomes of many Title VII and VIII programs were successful in meeting the goal of diversifying
the health care workforce. For example, according to a 2009 report issued by the American Public
Health Association, physicians who had graduated from the Title VII programs were two to four
times more likely than other graduates to serve in a medically underserved community.27 In fact,
on average, annually, these programs support the education and training of over 10,000
underrepresented minority graduates, residents, and faculty. Title VII programs have proven
particularly important to achieving workforce diversity in university settings. In many cases, these
programs were initiated with federal funding and were subsequently sustained by academic
institutions.
The ACA reauthorizes and provides additional support for many of the Title VII and VIII
programs, while also creating new opportunities to increase diversity in a range of health
professions. In this section, we describe the implementation progress of the ACA’s workforce
provisions which explicitly aim to increase racial and ethnic diversity and the number of providers
from underrepresented minority communities. These include provisions addressing the following
health professions:
•
•
•
•
•
•
Physicians and physician assistants (§5203, §5301);
Dentists (§5303);
Nurses (§5309, §5404);
Mental health providers (§5306);
Long term care providers (§5302); and
Community health workers (§5313).
Physicians and Physician Assistants
Legislative Context
Section 5301 amends Section 747 of the Public Health Service Act to authorize additional support
and funding for the previously established grant program for accredited primary care training and
enhancement in family medicine, general internal medicine, or general pediatrics. The ACA
lengthens the timeline of the program, expands the program’s scope and activities, and amends
funding priorities. This provision authorizes the U.S. Department of Health and Human Services
(HHS) Secretary to make 5-year grants to, or contracts with, an eligible entity—which may
include public and nonprofit private hospitals, medical schools, academically affiliated physician
assistant training programs, and other public and nonprofit private entities to:
• Develop and operate an accredited professional training program in family medicine,
general internal medicine, or general pediatrics, and provide need-based financial
assistance for these programs;
25
•
•
•
Develop and operate a training program for physicians who plan to teach in family
medicine, general internal medicine, or general pediatrics, and provide need-based
financial assistance for these programs;
Develop and operate a program for training physicians teaching in community settings;
and
Develop and operate a physician assistant education program.
Among other criteria, priority is given to eligible entities that have a record of training individuals
from underrepresented minority groups and familiarity in providing training in “cultural
competency and health literacy.” The law authorizes $125 million in fiscal year (FY) 2010 and such
sums as necessary for FY2011 to FY 2014 for primary care providers as well as 15% of that amount
appropriated for physician assistant training.
Section 5203 amends Section 775 of the Public Health Service Act by adding a new program—the
pediatric specialty loan repayment program—under which the eligible physician agrees to be
employed full-time for no less than two years in a pediatric medical subspecialty, pediatric
surgical specialty, or child and adolescent mental and behavioral health specialty. The law
explicitly states that priority is given to applicants that, among other criteria, have familiarity with
“cultural and linguistic competence” in health care services. The law authorizes $30 million for
pediatric medical specialists and pediatric surgical specialists for year FY 2010 through FY 2014,
and $20 million for child and adolescent mental and behavioral health professionals for each FY
2010 through FY 2013.
Implementation Status and Progress
Programs under Section 5301 include the Primary Care Residency Expansion Program (PCRE), the
Expansion of Physician Assistant Training Program (EPAT) and Grants for Primary Care Training
and Enhancement (PCTE). On September 27, 2010, HRSA awarded $167.3 million to fund 82
primary care residency training programs for 5 years under the PCRE program. Over this period,
the program is expected to train 889 new primary care residents. Primary care physician assistant
training programs also received funding for 5 years under the EPAT program. Twenty-eight
programs were awarded a total of $30.1 million which will fund 700 physician assistants by 2015.28
In subsequent years, the programs under this provision received $39 million for PCTE grants and
in FY 2013 a 30% increase of $51 million was requested.
According to the PCRE opportunity announcement, the program provides funding in the amount
of $80,000 per resident, per year, for three years. In addition, the announcement also specifies
that at the end of the grant period, each grantee should be able to demonstrate, along with other
metrics, that trainees are able to deliver “high quality, culturally and linguistically appropriate
care.”29 Programs are encouraged to monitor and track trainees for 5 years following the end of
the training program to gauge their effectiveness in providing such care; the ACA also authorizes
these programs to fund such analysis. However, the establishment of guidelines to carry this out
is subject to future appropriated funding. All funding was awarded in 2010 and recipients are
restricted in how much funding they may draw each year. No new funding for this program was
provided following FY 2010. For the PCRE program, which has received funding each year,
priorities outlined in the funding opportunity announcement include having a high rate of
placement of graduates in medically underserved communities, while the announcement for
EPAT specifies that evaluation criteria should address “the extent to which the applicant can
26
measure if PAs can deliver “high quality, culturally and linguistically appropriate care.” See Table
3 for details on originally authorized dollars in the ACA, the amount actually received for the
programs, and the requested amount for FY 2014.
Table 3. Authorized Funding in the ACA and Actual Funding for
Primary Care Providers, FY 2010-2014
FY 2010
Primary
Care
Training
FY 2011
FY 2012
FY 2013
FY 2014
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Requested
$125 m
$237
m*
SSAN
$39 m
SSAN
$39 m
SSAN
$37 m
SSAN
$51 m
Note: Auth = Authorized; SSAN = Such Sums as Necessary
*In FY 2010, $198 million was awarded from the Prevention and Public Health Fund in addition to the annual
discretionary amount of $39 million.
Finally, to date, no funding has been appropriated for the pediatric subspecialty loan repayment
program outlined in Section 5203. Funding in the amount of $5 million has been requested for FY
2014 to support this program.30
Emerging Programs and Models
A review of the 82 program descriptions funded under Section 5301 of the ACA reveal that
virtually all are targeting services to underserved populations, and at least 32 (40%) explicitly
mention expanding their programs to include more racially and ethnically diverse trainees or
addressing cultural competency. The large majority of these programs have created opportunities
for primary care residents to serve in underserved communities, either through their own
institution or in partnership with Federally Qualified Health Centers, community hospitals, and
other community-based health care settings. These programs typically also include experience
related to serving in a patient-centered medical home. Other common elements described
include offering incentives to graduates to stay and practice in the underserved settings in which
they were trained and providing didactic curricula in cultural competency to supplement the
diverse training experiences received. In order to recruit students who are committed to serving
such populations, many programs describe recruiting medical students who are originally from
the area with high unmet needs. Following are examples of primary care residency programs
funded under the ACA that aim to expand diversity, improve cultural competency, and expand
service in underserved communities:
•
Baylor College of Medicine’s Department of Family Medicine (Houston, Texas)
received $640,000 to expand the number of primary care residents it trains, particularly
following financial setbacks which led the program to reduce the number of trainees in
2010. Recognizing that Non-White racial and ethnic residents are more likely to remain in
primary care practice, the program has made a concerted effort to promote ethnic
diversity and increase minority representation among its learners.31 As the program
abstract cites, “since 2004, underrepresented minorities comprise 47% of the total number
of residents in the program and provide 50% of their care in medically underserved
communities.”32 Funding through the ACA will be used to re-grow the department, as well
as ensure that primary care residents provide care to medically underserved patients
within the Harris County Hospital District (HCHD) for at least 6 months at every Post27
Graduate Year (PGY) level. Along with tracking residents’ placement, as an incentive, the
program offers “graduates the ability to retain employment within the department and
continue serving patients of the HCHD.”33
•
The Crozer-Keystone Health System Family Residency Training Program
(Springfield, Pennsylvania) received $1.92 million to expand its program to meet
increasing demand for primary care services at its new outpatient training facility in
Upper Darby, Pennsylvania, a medically underserved area. Residents will receive
outpatient training and experience to serve a largely urban, uninsured, and diverse patient
population. “Darby has emerged as a resettlement location for immigrants and refugees in
the region, and at least 15% of the population is composed of immigrants, including most
recently large numbers of West Africans, Central and South Americans, and Mexicans.34
The program has a track record of placing 100% of its residents, to date, in primary care
settings. Through new funding the project intends to develop resident competencies
needed to provide quality care to underserved populations upon graduation.35
•
Children’s Hospital of Pittsburgh of UPMC (Pittsburg, Pennsylvania) received $1.92
million to expand its pediatric residency program and create a new pathway, Primary
Care-Advocacy-Leadership-Service (PALS)—designed to train its residents to care for
underserved children in rural and urban communities. The program description states the
grantee will provide “learning experiences that enhance residents’ understanding of key
community health issues, such as health disparities, cultural competence, and health
policy. […] Residents will also be engaged through didactic and experiential curricula that
support the provision of culturally competent and effective care to children living in
poverty.”36
•
University of California, San Diego (San Diego, California) received $2.88 million to
expand its Family Medicine Residency Program to better meet the needs of the
surrounding community, a border population experiencing an inadequate number of
Spanish-English bilingual and culturally competent health care professionals. Over six
months of training is provided in a Federally Qualified Health Center—i.e., Chula Vista
Family Clinic. In addition, the University carefully screens its applicants for qualities
demonstrating a commitment to providing care to medically underserved and underinsured patients such as experience with community outreach. As such, the program
actively recruits medical students who attended high school in the San Diego border area.
By implementing these activities, the school places a large number of graduates who are
providing comprehensive primary care to such populations in the region and plans to
maintain this record with new funding.
Challenges and Next Steps
The ACA’s commitment to supporting primary care providers represents an important step to
meeting provider shortages, particularly in rural and inner city areas with large and growing
diverse populations. 37,38,39 With an emphasis on increasing the number of underrepresented
minorities and ensuring new residents are trained in culturally and linguistically diverse
settings—such as medically underserved areas, community health centers, and new care
arrangements such as the Patient-Centered Medical Homes—these efforts have great potential to
improve access, quality, and outcomes of care for diverse patients. However, there is widespread
28
acknowledgement that the expansion funded through this provision—an estimated 889 new
physicians and 700 new physician assistants by 2015— is only a small portion of what will be
needed to adequately meet the nation’s primary care workforce needs. The Association of Medical
Colleges estimates that an additional 21,000 primary care physicians will be needed by 2015.40 And
without appropriated funding for Section 5203, the pediatric subspecialty workforce is likely to
continue to face shortages and be insufficient to meet new demands. As it is, pervasive and
persistent racial and ethnic disparities exist across a range of pediatric health and health care
measures, including mortality, access to care, utilization of services, adolescent health, chronic
diseases and special needs care.41 This provision offers an important opportunity to improve
access to pediatricians and pediatric subspecialists in underserved areas, while ensuring diversity
and promoting cultural competence and linguistic access—efforts which are core to effectively
caring for a growing racially and ethnically diverse pediatric patient population.
Dentists
Legislative Context
Section 5303 establishes a new grants program for training in general, pediatric, and public health
dentistry by amending Section 748 of the Public Health Service Act. Grants or contracts are
awarded for 5 years and available to schools of dentistry, hospitals, and non-profit organizations
to develop and operate dentistry training programs with an emphasis on general, pediatric, or
public health dentistry as well as to provide financial assistance to students who plan to work in
these fields. Among other criteria, priority for grant awards is given to entities that have a record
of training individuals from underrepresented and disadvantaged groups that provide training in
“cultural competency and health literacy,” and have a record of placing trained professionals in
settings experiencing health disparities. The law authorizes $30 million for FY 2010 and such sums
as necessary for FY 2011 through FY 2015.
Implementation Status and Progress
Grants under this provision were funded in FY 2010 to FY 2013. In FY 2010, $15 million were
appropriated, in FY 2011 $17 million were appropriated, in FY year 2012, $20 million were
appropriated, and in FY 2013, $19 million were appropriated. (Table 4). For FY 2014, $21 million
were requested.
Table 4. Authorization and Actual Appropriation of Section 5303 Funding
FY 2010
Sec.
5303
FY 2011
FY 2012
FY 2013
FY 2014
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Requested
$30 m
$15 m
SSAN
$17 m
SSAN
$20 m
SSAN
$19 m
SSAN
$21 m
Note: Auth = Authorized; SSAN = Such Sums as Necessary
Emerging Programs and Models
A review of active programs reveals that virtually all express a priority for targeting racially and
ethnically diverse dental students, focusing on culturally competent training, and delivering
dental services to diverse patient populations. These programs aim to address health disparities
29
through a range of actions. First, for example, many grantees are offering a dual Master of Public
Health and Dentistry degree program with the intention of bridging the knowledge gap between
oral health and general health, as well as to expand the number of dentists with public health
training. Some programs offer stipends and tuition support to encourage completion of the public
health degree. Many of these programs explicitly incorporate health disparities in their
curriculum.
Secondly, grantees are using funding to enhance their training curricula to include an increased
focus on vulnerable and underserved populations and their unique oral health needs. For
example, some programs underscore the importance of risk assessments for certain oral diseases
among specific vulnerable and diverse communities. The merging of such didactic learning with
training in community settings such as Federally Qualified Health Centers is affording the unique
opportunity for trainees to gain heightened awareness and practical knowledge of the application
of cultural competency and health literacy principles. Some programs are making these
community-based trainings in underserved communities a requirement rather than an elective to
ensure maximum participation.
Following are examples of programs which highlight actions and efforts specifically addressing
diversity, equity, and cultural competency:
•
Case Western University: Through funding from the ACA, Northeastern Ohio
Predoctoral Training in Dental Public Health is offering additional training to its students
through its dual Doctor of Dental Medicine Degree and Master’s of Public Health Degree.
Under this program, second year students are trained to identify oral diseases among
underserved populations as well as receive training in cultural competency and health
literacy curricula. The program description states: “The training sites have been carefully
chosen to increase residents’ cultural sensitivity and understanding, particularly about two
underrepresented minority groups: African-Americans and Hispanics. The program will
make a concerted effort to recruit trainees from the aforementioned minority groups, and
the trainees will be working with the homeless and migrant farm workers.”42
•
University of Pittsburgh: The University aims to improve its number of graduates
practicing in underserved areas by expanding training opportunities in underserved areas.
The grantee is augmenting the current curricula to incorporate cultural competency
objectives and include community-based clinics. According to the program description,
the University understands that “the inclusion of advanced students in our program will
increase their level of comfort in the delivery of dental medicine to high-need and lowaccess populations, and heightened cultural competency will dismantle existing barriers
that impede graduates from having the skills and desire to practice dental medicine in
rural and other underserved communities.”43
•
University of Texas Health Science Center at San Antonio: The San Antonio Dental
Public Health and Diversity Pre-Doctoral Education Program is continuing its
comprehensive dental public health curriculum. The program description states, “It is
through the education of a competent and culturally responsive workforce that this
program seeks to address these ever-widening gaps in oral health and disparities in access
to oral health services.”44 This objective is achieved through community-service learning
opportunities and a focus on cultural competency training. Among the program’s goals is
30
to increase student diversity through “pipeline” programs for students expressing interest
in dental public health with the intention of serving the communities in South Texas who
experience substantial disparities in oral health needs.
Challenges and Next Steps
While grants and contracts have been awarded under this provision, the funded amount did not
equal the total amount authorized under the law in the first year. The ACA authorized $30 million
in FY 2010, but only $15 million were appropriated. Nonetheless, the program has received
continued support over the years, and given the large disparities in oral health and shortage in
dental providers, particularly in underserved areas, adequate funding for this provision is
required. In fact, it has been suggested that without aggressive intervention to ensure that an
adequate supply of dentists are available and willing to serve in vulnerable and diverse
communities, the current incongruence in representation of race and ethnicity will be
exacerbated as our population demographics quickly change.45
Nurses
Legislative Context
Section 5404 of the ACA amends Title VIII, Section 821 of the Public Health Service Act, modifying
the original Nursing Workforce Diversity Program “to include advanced education preparation,
stipends for diploma or associate degree nurses to enter a bridge or degree completion program,
and student scholarships or stipends for accelerated nursing degree program students.”46 This
provision also adds the National Coalition of Ethnic Minority Nurse Associations as a consultant
organization to the HHS Secretary on issues related to nursing diversity. No funding
specifications are provided in the ACA.
Section 5404 complements a series of other programs in the ACA to enhance the nursing
profession, including:
• Section 5308, which modifies the Advanced Nursing Education Program;
• Section 5309 which amends the Public Health Service Act to authorize funding for Nurse
Education, Practice, and Retention Grants through FY 2014;
• Section 5310, which modifies eligibility for the Loan Repayment and Scholarship Program;
• Section 5311, which amends the Public Health Service Act to authorize new funding for the
Nurse and Faculty Loan Program through FY 2014; and
• Section 5312, which makes available $388 million for nurse workforce development for FY
2010 and such sums as may be necessary for FY 2011 through FY 2016.
Given that these programs do not explicitly cite or mention details related to diversity and
cultural competency in the ACA, a comprehensive review and analysis of these nursing provisions
is beyond the scope of this report. Nonetheless, we provide identified updates, particularly in the
context of their role and promise in enhancing nursing opportunities among racially and
ethnically diverse communities.
31
Implementation Status and Progress
In December 2010, HRSA released a Funding Opportunity Announcement (FOA) to support its
Nursing Workforce Diversity initiative and train disadvantaged students, including racial and
ethnic minorities, to enter nursing professions at various levels. The FOA was intended to
support students at eligible institutions to become registered nurses, assist diploma or associate
degree registered nurses to become baccalaureate-prepared registered nurses, and prepare
registered nurses for advancing nursing education. The FOA was explicitly geared toward
increasing the number of individuals who are from “disadvantaged backgrounds (including racial
and ethnic minorities underrepresented among registered nurses)” in these programs.47 Eligible
applicants included accredited schools of nursing, nursing centers, academic health centers, state
or local governments, and other private or public entities determined appropriate by the HHS
Secretary, including faith-based and community-based organizations, and tribes and tribal
organizations.
On July 29, 2011 HHS announced that it had awarded approximately $3.6 million to 11 grantees as
part of the Nursing Workforce Diversity program. These grantees are listed in Table 5. Appendix
B details the total number of active grants each year as well as the appropriated funding amount.
Table 5. Nursing Workforce Diversity Grants, FY 2011
Grantee
University of Connecticut
Albany State University
Allen College
State
Connecticut
Georgia
Iowa
Amount
$334,802
$311,875
$312,490
University of Maryland, Baltimore
Regents of The University of Michigan
Montana State University
University of North Dakota
Community College of Allegheny County
Alvernia College
University of Tennessee Health Science Center
Maryland
Michigan
Montana
North Dakota
Pennsylvania
Pennsylvania
Tennessee
$304,073
$390,853
$277,535
$515,631
$399,031
$110,880
$269,012
Source: Health Resources and Services Administration. “Nursing Workforce Grants by State and Grantee.” Available at:
http://www.hrsa.gov/about/news/2011tables/nursingbyrecipient.html
Also on July 29, 2011, HHS announced $67.7 million additional in grant awards for Nursing
Development Programs.48 As cited in its press release, the following programs and awards were
made by HHS:
•
Nurse Education, Practice, Quality and Retention ($10.9 million – 33 awards):
Strengthens nursing education and practice capacity by supporting initiatives that expand
the nursing pipeline, promote career mobility for nurses, prepare more nurses at the
baccalaureate level, and provide continuing education training to enhance the quality of
patient care. The ACA modified the program to enhance its focus on activities that help
improve nurse retention.
32
•
Nurse Faculty Loan Program ($23.4 million – 109 awards): Assists registered nurses in
completing their graduate education to become qualified nurse faculty. Through grants to
eligible entities, offers partial loan forgiveness for borrowers that graduate and serve as
full-time nursing faculty for the prescribed period of time. The ACA increased the annual
loan limit to $35,500 from $30,000 and established a priority for doctoral nursing students.
•
Advanced Nursing Education Program ($16.1 million – 55 awards): Supports advanced
nursing education specialty programs that educate registered nurses to become nurse
practitioners, clinical nurse specialists, nurse anesthetists, nurse-midwives, nurse
educators, nurse researchers or scientists, public health nurses and other advanced nurse
specialists.
•
Advanced Education Nursing Traineeships ($16 million – 349 awards): Funds
traineeships at eligible institutions for registered nurses enrolled in advanced education
nursing programs. Traineeships prepare nurse practitioners, clinical nurse specialists,
nurse-midwives, nurse anesthetists, nurse administrators, nurse educators, public health
nurses and nurses in other specialties requiring advanced education. The ACA removed
the 10% cap in this program that limited the amount of support that could go to nursing
students pursuing doctoral degrees.
•
Nurse Anesthetist Traineeships ($1.3 million – 76 awards) Supports traineeships at
eligible institutions for licensed registered nurses enrolled as full-time students in their
second year of a two-year nurse anesthetist Master's program.
Emerging Programs and Models
In a Nursing Workforce Diversity FOA issued in December 2010, HRSA explicitly required eligible
entities to describe their commitment and activities related to advancing diversity and cultural
competency.49 In addressing diversity, institutions were required to report: (1) their strategic
commitment to increasing the number of culturally competent and diverse health professionals;
(2) their successful strategies for recruiting and retaining diverse students; (3) provision of
resources to promote matriculation of individuals from disadvantaged and diverse backgrounds;
and (4) provisions of financial assistance to these students. On the topic of cultural competence,
entities were required to describe the institution’s strategic commitment to this priority
particularly in the provision of services and in developing a culturally and linguistically competent
staff, faculty, and program. In addition, institutions were required to report on their past
experience recruiting and retaining health care staff with experience in cultural competence,
along with existing programs, training and technical assistance and future plans addressing:
•
Cross-cultural communication to foster healing relationships;
•
Self-awareness of multicultural and health literacy issues;
•
Engagement of individuals, families, and communities from diverse social, cultural, and
language backgrounds in self-managing their health care; and
•
Knowledge and appreciation of how culture and language influences health literacy; and
the delivery of high quality, comprehensive, culturally competent, effective health care
services.50
33
A review of the Nursing Workforce Diversity Grants program descriptions reveals that, by the
nature of the provision, all incorporate a focus on diverse, underrepresented and disadvantaged
nursing students. This goal is achieved through activities such as pipeline programs, improving
nursing retention in college, financial stipends to increase graduation rates, and improving upon
cultural competency and cultural awareness strategies. The University of Maryland, for example,
provides culturally specific information about opportunities in nursing to pre-college students—
the grantee prepares high school students from low-performing high schools for enrollment in a
college pre-nursing program. Albany State University aims to improve graduation rates for
minority and disadvantaged students by 50%, and college retention rates for nursing students by
fostering a learning community with peer tutoring and mentoring activities. The Community
College of Allegheny County describes strengthening cultural competency initiatives through
“cultural competence assessments and in programs and presentations designed to increase
cultural awareness and the importance of cultural competence in health care.”51
In a review of active grant programs for the Nurse Education, Practice, Quality and Retention
program, all programs address vulnerable populations such as minorities, geriatric populations,
and individuals in rural areas. Of these, at least 40% explicitly address inclusion of racially and
ethnically diverse populations or the provision of culturally competent care. For example, George
Washington University School of Nursing targets racially and ethnically diverse baccalaureate
nursing students, or those from rural areas to participate in its “Teaching and Transforming
through Technology Program” by breaking down geographic and access barriers through
eLearning and blended format teaching strategies. Ashland University has outlined its program
objectives to include improved marketing to minority students to increase diversity in
enrollment, to improve the retention of such students by 3%, to ensure that simulated learning
opportunities include culturally appropriate examples as well as to increase diversity among
faculty to encourage the recruitment of minority students and to encourage faculty development
in diversity issues. The University of Texas Health Science Center is developing a bridge program
by partnering with the pre-nursing program at University of Texas San Antonio, and enhancing
the mentoring program to that University for better student retention. An added focus on
community is utilized to reach its goals of culturally competent nursing practices.
Challenges and Next Steps
There is growing recognition of the need for a nursing workforce that is representative of the
country’s changing demographics. Nursing schools have typically addressed this challenge
through two pathways: increasing the number of racially and ethnically diverse nursing students
and faculty, and enhancing their cultural competence.52 Both of these avenues face unique
barriers. In general, there is little consensus regarding the efficacy of individual retention
strategies for matriculating diverse nurses. One study reported that financial assistance and
computer technology support strategies were most promising, while mentoring programs were
less successful.53 Understanding the degree to which curricula related to cultural competency is
effective in training a workforce that is sensitive to the needs of patients from diverse heritage is
even more challenging. In fact, being from a racially or ethnically diverse background does not
necessarily translate to practicing culturally competent nursing care. It has been found that
varying levels of acculturation, proficiency in the English language, education, and literacy affect
the degree of a provider’s cultural competence.54
34
There exists limited research to date evaluating the efficacy of cultural competence training in
nursing. However, the current available evidence shows that there are still improvements to be
made in cultivating educational environments that foster trust and cultural awareness. In an
evaluation comparing the educational environment of a baccalaureate nursing program and that
of a recipient of a Nursing Workforce Diversity grant, it was found that the climate of the grantee
ranked more highly in survey domains such as “caring and respect” and “atmosphere.” Although
students reported general satisfaction with both programs under study, cultural competency and
tolerance were areas students indicated needed improvement.55
Several prominent barriers stand to slow the progress of assuring cultural and linguistic
competency in nursing curricula. For example, there is a lack of consistency and standardization
in content, process, and outcomes of such curricula across nursing programs and schools. This
challenge is exacerbated by the presence of numerous programs for entering the nursing
profession.56 It has also been reported that competing priorities exist among schools that face
increasing demand to increase enrollment of nurses in order to address workforce shortages.
Academic institutions may funnel resources to “enrollment management” and away from
programs aimed at enhancing their cultural and academic environments, including efforts to
recruit and retain a racially and ethnically diverse student body.57 This point is also highlighted in
the Nursing Community Consensus Document, undersigned by numerous nursing organizations:
While nursing has made great strides in recruiting and graduating nurses that mirror the
patient population, more must be done to keep pace with the changing demographics of
58
our country to ensure that culturally sensitive care is provided.
Mental Health Providers
Legislative Context
Section 5306 of the ACA amends Sections 750 and 756 of the Public Health Service Act which
authorizes the Mental and Behavioral Health Education and Training Grants (MBHETG)
Program. Under this program, grants are made to academic institutions or professional training
programs to recruit students into education programs for social work and psychology, programs
that are developing or expanding internships or field placement opportunities in child and
adolescent mental health, and training programs for paraprofessional child and adolescent mental
health workers. Diversity of individuals participating in the institution, including diversity in race,
ethnicity, culture, geography, language, religion, socioeconomic status, gender, and sexual
orientation, is among the criteria for eligibility for a grant award. Furthermore, according to the
law, the eligible institution should demonstrate that “any internship or other field placement
program assisted under the grant will prioritize cultural and linguistic competency.” Under the
law for FY 2010 to FY 2013, $8 million are authorized for social work programs, $12 million are
authorized for training in graduate psychology programs, $10 million are authorized for training
in professional child and adolescent mental health, and $5 million are authorized for training in
paraprofessional child and adolescent mental health.
35
Implementation Status and Progress
On September 25, 2012, HHS Secretary Sebelius announced that nearly $10 million dollars were
awarded to 24 graduate social work and psychology academic institutions ranging from $121,000
to more than $480,000 per school (Table 6).
Table 6: Mental and Behavioral Health Education and Training Grantees, FY 2012
Grantee
Western Interstate Commission for Higher Education
University of Florida
University of Hawaii
University of Kansas Medical Center Research Institute
University of New England
Hugo W. Moser Research Institute at Kennedy Krieger Inst.
Trustees of Boston University
Regents of the University of Michigan
Regents of the University of Minnesota
The Curators of the University of Missouri
University of Nebraska
Research Foundation of State University of New York
RFCUNY - Lehman College
Mount Sinai School of Medicine
New York University
Yeshiva University
Children’s Hospital of Philadelphia
Trustees of the University of Pennsylvania
Medical University of South Carolina
University of Texas at Austin
University of Houston
Texas State University-San Marcos
Norfolk State University
West Virginia University Research Corporation
State
Colorado
Florida
Hawaii
Kansas
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Nebraska
New York
New York
New York
New York
New York
Pennsylvania
Pennsylvania
South Carolina
Texas
Texas
Texas
Virginia
West Virginia
Award
$354,253
$251,999
$331,201
$240,000
$480,000
$121,096
$480,000
$480,275
$440,000
$474,174
$480,000
$480,275
$479,973
$225,570
$466,666
$470,862
$192,000
$479,331
$469,404
$480,275
$468,000
$479,035
$458,277
$476,263
Emerging Programs and Models
All grantees funded under Section 5306 describe programs that are targeted to high-needs and
high-demand populations, which include medically underserved communities, individuals with
disabilities, veterans, low-income populations, among others. At least 10 of the 24 programs
explicitly address racial and ethnic diversity. Grantees describe a number of strategies that will
enhance training for their students and interns with a specific focus on recognizing and
addressing mental health needs of individuals from medically underserved areas, many of whom
are racially and ethnically diverse. For example, many schools are revising and augmenting
current didactic curricula to emphasize mental health disparities among low-income, vulnerable,
and underserved groups.
Another common theme surfaced around revising current, or providing new, clinical trainings
that are targeted specifically to patients who lack access to appropriate mental health services.
36
This includes, for several programs, partnering with behavioral health clinics that serve
vulnerable and diverse populations. Finally, the role of telehealth was a theme described among
several grantees. One especially promising strategy for improving access to care among hard-toreach populations, who are diverse in geographic location, socioeconomic status, race, and
ethnicity, involves training student interns to use telehealth systems for mental health screening,
assessment, and treatment.
Following are examples of grantee programs which reflect a commitment to addressing diversity,
equity, and cultural competency by ensuring training opportunities are focused in serving
communities of color, and professionals are better prepared to serve those individuals:
•
University of Hawaii: Through new funding, the University plans to add 2-3 new predoctoral internship trainees who will specialize in treating patients of diverse racial,
ethnic, socioeconomic, and geographic backgrounds. According to the program
description, “the purpose is to increase the number of scientist-practitioner clinical
psychologists committed to working with underserved, rural, ethnically diverse groups,
who provide culturally-competent, evidence-based psychological services in an
interdisciplinary team context.”59
•
University of Michigan: The University of Michigan’s program has extensive goals to
eliminate health disparities among communities in Detroit and Wayne County. The
grantee aims to implement an interdisciplinary training curriculum with emphasis on
better preparing social workers to serve diverse children and adolescents. This goal is
being achieved through increasing the number of internships in disadvantaged local
communities in partnership with behavioral health clinics serving these groups, as well as
increasing the number of social workers who will continue to serve these populations.
•
University of Missouri: This grantee is increasing the number of psychologists who will
provide services to persons with chronic disease in rural areas. Curricula and experiential
training will be augmented by adding the course “Culture and Health Literacy” to
students’ educational experiences in order to improve cultural and linguistic competency.
This program will evaluate its outcomes through quantitative and qualitative measures,
including number of interns from diverse racial and ethnic backgrounds who complete the
internship, increases in cultural competencies, and number of interns who go on to
practice in underserved or rural areas.
•
Children’s Hospital of Philadelphia: This grantee is using funding from the ACA to
better prepare psychology interns and fellows to treat underserved populations, especially
low-income and racially and ethnically diverse children with mental health problems.
Culturally competent practices are emphasized with students training in sites such as
urban primary care practices and schools. According to the program description, “clinical
training will be complemented by participation in a progressive series of didactic
seminars. Each seminar series focuses on issues related to individual and cultural
diversity, particularly working within medically underserved communities.”60
Beyond these programs and the ACA, several states have explicitly recognized the importance of
cultural competency training and require or recommend that mental health professionals receive
such education through their degree curricula, continuing education, or requirements for
37
licensure.61 At least three states have implemented legislation requiring these objectives. New
Jersey enacted legislation in 2005 requiring a pre-specified number of hours of cultural
competency training to receive medical licensure. It also requires medical schools to incorporate
learning objectives into their curricula focusing on racial and gender disparities in medical
treatment. California passed a law in 2005 that mandates integrated cultural competency
objectives into health care degree curricula moving away from models that require singular
classes or set number of training hours. Washington passed legislation in 2006 requiring health
professional schools to provide education in multicultural health by a specific deadline. The
regulatory agency for health professions is also required to implement education programs in
multicultural awareness under the law. Maryland has enacted voluntary legislation for cultural
and linguistic competency and at least nine states have introduced but not passed laws around
these competencies in program curricula, continuing education, and licensure processes.62
Challenges and Next Steps
The HRSA Office of Shortage Designation has identified 3,059 Mental Health Professional
Shortage Areas, which includes 77 million residents, many of whom are racially and ethnically
diverse. To achieve the recommended population-to-practitioner ratio, 5,145 providers are
required.63 It is clear that while these funded grants are an important start to meeting the needs of
diverse populations experiencing disparities in mental health services, a continued commitment
to this goal is necessary to fill the immense void. Furthermore, not all funded programs have clear
goals for cultural competency training among mental health providers. Much can be learned from
the few states that have taken innovative steps to integrate cultural competency into mental
health professional training and licensure.
In an analysis of regulatory and legislative actions for cultural competency in 14 states, several
common activities associated with positive outcomes and barriers to implementing these
activities were identified. For example, leveraging support from the executive branch and drawing
from successful lessons learned in other states proved to be indicators of positive results. Barriers
identified included bill sponsorship without important, if not, essential support backing from
advocacy and consumer groups or other legislators or opposition from associations representing
health care professions or higher educational institutions protective of professional scope. Other
challenges reported included legislative leadership that failed to view cultural competency
training as a high priority as well as the incorrect association some legislators made in linking the
support of cultural competence training with undocumented immigration.64
Long Term Care Providers
Legislative Context
Section 5302 of the ACA amends Title VII of the Public Health Service Act by authorizing $10
million for FY 2011 to FY 2013 to fund a novel program that provides grants to higher education
institutions to train direct care workers. These institutions should have partnerships with entities
such as nursing homes, skilled nursing facilities, home health care agencies or other long-term
care providers. Grants will provide financial assistance to students who commit to working in the
fields of geriatrics, disability services, long-term care, among others for a minimum of two years.
While there is not explicit language related to diverse populations, this provision holds promise
for advancing the health of such communities as a significant percentage of the direct care
38
workforce is made up individuals from racially and ethnically diverse heritages.
Implementation Status and Progress
No funding has been appropriated for this provision, to date.
Emerging Programs and Models
While this provision lacks funding and has gone unimplemented, the development of the direct
care workforce and related priorities are being addressed under other funded provisions of the
ACA. For example, Section 5507 established demonstration projects for six states which are
currently being implemented. Under this provision, states receiving funds for demonstration
projects are tasked with developing core competencies for direct care workers to help to
strengthen their competencies explicitly related to communication, cultural and linguistic
competence and sensitivity, problem solving, behavior management, and relationship skills,
among others. In addition, they are creating foundational trainings and protocols as well as a
certification test to continue to develop and standardize such core competencies. Section 5309
provides community college and community-based training programs for nursing assistants and
home health aides. The provision provides funding for the Nursing Assistant and Home Health
Aide Program which supports nursing assistants and home health aides in their career
development. Training programs are currently being implemented to ensure that these workers
have the necessary skills to provide care in a complex health care environment. Funding also
supports a “career ladder” to support nursing assistants, associate degree nurses, and others train
and prepare for baccalaureate-level registered nursing programs or other advanced degree
nursing programs.
Challenges and Next Steps
Residual uncertainty around the value of investment in direct care jobs has likely hindered
opportunities for their funding and prioritization. Jobs classified under this profession, such as
home health care aides, have been perceived as “dead end” due to high turnover and a lack of
formal training requirements.65 In addition to low wages and poor benefits, direct care workers
commonly experience occupational injuries. However, developing improved training
requirements and clear professional standards and guidelines for this occupation will likely
improve overall job quality, thereby offering the potential for substantial improvements for its
workforce, many of whom are racially and ethnically diverse, and simultaneously improve the
quality of patient care.
Community Health Workers
Legislative Context
Section 5313 establishes a novel grants program to promote positive health behaviors and
outcomes for populations in medically underserved communities through the use of Community
Health Workers (CHW). The CHW program is intended to educate and provide outreach in
community settings regarding health issues prevalent in medically underserved and diverse areas.
A CHW is defined by the Department of Labor as "an individual who promotes health or nutrition
within the community which the individual resides" by, among other actions, "providing
culturally and linguistically appropriate health or nutrition education."66 The law specifies that
39
grants should be used to support CHWs “to educate, guide, and provide outreach in a community
setting regarding health problems prevalent in medically underserved communities, particularly
racial and ethnic minority populations.” Such sums as necessary are authorized under the ACA to
carry out this provision for FY 2010 to FY 2014.
Implementation Status and Progress
This provision of the ACA has not been funded, although opportunities and priorities for
community health workers have been funded through other sections of the ACA, such as the
Community Transformation Grants (Sec 4201). For example, the Douglas County Health
Department in Nebraska, is implementing a Community Transformation Grant to enhance local
initiatives to promote tobacco-free living, increased physical activity and healthy eating strategies,
clinical quality and preventative services, among other objectives. OneWorld Community Health
Center is partnering with the department to provide a community health worker to assist
underserved populations with blood pressure and cholesterol management. The Texas
Department of State Health Services is also working with CHWs to provide culturally appropriate
care to underserved populations through its Community Transformation Grant titled
“Transforming Texas.” The intent of this program is to work with CHWs to reduce chronic
diseases, lower the cost of care, and promote active and healthy living through expanding access
to care for vulnerable populations with high rates of chronic disease.
Emerging Programs and Models
There is increasing evidence of the effectiveness of using CHWs to reduce the burden of chronic
disease especially among underserved, low-income, and diverse patient populations. Efforts to
leverage this unique workforce are evident in cancer initiatives as the Division of Cancer
Prevention and Control (DCPC) reports that 35 state cancer control plans include references to
CHWs, patient navigators, outreach workers, community health representatives, promotores,
community health advisors, lay health educators, lay health advisors, or peer educators.67
Other community health worker initiatives being implemented outside of the ACA serve as
models and best practice examples for successful strategies to reach out to and serve diverse
populations. A common characteristic of these programs—which is essential to caring for
underserved communities—is a close connection (whether it be through shared race, ethnicity,
language or other experiences) to the target population. This is frequently seen as a central
requisite needed to ensure that the services provided are culturally and linguistically appropriate,
which does not always occur when receiving care through traditional health care
routes. Examples of such programs include the Division for Diabetes Translation (DDT) in Rhode
Island which has partnered with the Diabetes Multicultural Coalition to train CHWs to teach
diabetes self-management to members of diverse populations. DCPC has also partnered with
Florida, Texas, Georgia, and the U.S.-Mexico border to include CHWs (known in Spanish as
promotores) to improve patient education and care.68 In addition, 18 of the 40 Racial and Ethnic
Approaches to Community Health (REACH) coalitions in the U.S. rely on CHWs as a grassroots
empowerment strategy to reduce health inequities among various populations and to improve
health outcomes.69
The administration of CHW initiatives varies greatly across states, but several states offer
promising examples for effective funding models and implementation efforts. For example,
Minnesota is one of the only states that offers Medicaid fee-for-service reimbursement for these
40
workers since its initiation of an 1115 Medicaid Waiver to allow for such reimbursement in 2007.70
The Blue Cross Foundation in Minnesota has promoted culturally competent care in underserved
communities by funding the Minnesota Community Health Worker Alliance which oversees a
standardized curriculum and certification program for community health workers.71
Massachusetts also stands out as a state making significant progress in supporting community
health worker programs to target health disparities. After extending health insurance coverage to
an expanded patient population in 2006, the state relied on contributions from community health
workers to effectively reach out to and enroll uninsured and under-insured individuals and
formally recognized such efforts in its health care reform legislation. Through this legislation, the
state provided Outreach and Enrollment Grants to eligible community-based organizations for
enrollment assistance into the law’s new coverage options, and most grantees used CHWs to do
so.72 The state’s Massachusetts Association of Community Health Workers, in partnership with
several other entities, offers specialized training and education for CHWs to provide services to
Latino and African American communities with high rates of chronic diseases.
Challenges and Next Steps
There are clear challenges that continue to threaten the CHW workforce. In addition to the
absence of funding for this specific provision, other funding challenges persist. Throughout the
nation, grants for community health workers frequently cover limited time frames or scope
causing periodic gaps in program operations or uncertainty over future programs. Many states
also lack standard certification criteria for CHWs, which is a necessary component for the
development of this field.73 It is well-documented that CHWs are vital to implementing effective
outreach to racially, culturally, and linguistically diverse populations and are leaders in providing
culturally competent care. As a result, current setbacks and delays in development of this unique
facet of the health care workforce may also slow broader health equity objectives.
41
B. Workforce Support for the Health Care Safety Net
Background
While the large majority of workforce provisions discussed in this report have implications for the
health care safety net, there are at least three that explicitly target programs within public
hospitals, community health centers, and other safety net settings. In this section, we discuss the
implementation status, progress, and challenges related to these provisions:
•
•
•
Section 5207: Funding for National Health Service Corps;
Section 5403: Interdisciplinary, community-based linkages; and
Section 5503: Distribution of unused residency slots.
Since 1972, The National Health Service Corps (NHSC), authorized under the Public Health
Service Act, has encouraged residents to commit to providing care in medically underserved areas
through financial incentives such as loan repayments or scholarships. Research has indicated that
having participated in the NHSC independently predicts whether physicians provide care to
underserved populations.74 One source estimates that half of these providers practice in HRSAsupported health centers delivering care to a population that is largely uninsured.75 However, this
program has a history of limited funding to support as many positions as there were vacancies in
shortage areas.76 This provision of the ACA aims to address this challenge by maintaining and
increasing support for the NHSC.
Another program which encourages medical practice in underserved areas is the Graduate
Medical Education (GME) Loan Repayment Program. Access to care for residents of rural and
medically underserved areas is a well-known challenge. It has been suggested that the problem
may be worsened by a common practice: GME funding to urban teaching hospitals frequently
leads to physician trainees remaining in these urban settings where they receive training.77 This
challenge is especially concerning for racially and ethnically diverse individuals residing in rural
areas as barriers in access to care are greater for these populations. For example, Hispanics living
in rural areas are less likely than their urban-residing counterparts to have a usual source of care
(72% versus 77%).78 It has also been found that rural areas with a Hispanic population greater
than 50% had lower physician density ratios and residents faced longer travel distances to
physicians and hospitals than individuals in rural areas populated predominantly by NonHispanic Whites.79
Finally, the Area Health Education Center (AHEC) program supports partnerships between
nursing and medical schools and community-based centers to provide training opportunities that
are designed to enhance the supply and distribution of the healthcare workforce. Training
opportunities largely focus on primary and preventative care and are targeted to underserved
populations such as migrants, individuals in rural areas, community health clinic patients, among
others. The AHECs further provide continuing education to health care providers and direct
outreach initiatives addressing issues around service delivery and access for underserved
populations. Community partnerships such as these have been identified as effective in recruiting,
preparing, and retaining a diverse body of health professions students.80
42
National Health Service Corps
Legislative Context
Section 5207 of the ACA reauthorizes the NHSC as well as increases monetary support for the
program by authorizing new dedicated funding in the amount of $1.5 billion for FY 2011 through
FY 2015. Starting in 2016, funding will be adjusted based on the costs of health professions
education and increases in the population residing in health professional shortage areas.81
Implementation Status and Progress
On October 13, 2011, the U.S. Department of Health and Human Services (HHS) announced grant
awards for the NHSC. The ACA, along with other funding sources, funded 5,418 awards for NHSC
loan repayment programs, and $46 million in mandatory funding from the ACA went to the
NHSC scholarship program.82 Additional funding was announced for NHSC programs on
February 13, 2012: a pilot program titled “Student to Service” established loan repayment
incentives up to $120,000 to fourth year medical students in exchange for service commitments in
health professional shortage areas.83 On October 11, 2012 the HHS announced the ACA-funded
loan repayment and scholarship awards in the amount of $229.4 million for 4,600 awards and
state grants.84
Under the ACA, the NHSC workforce has grown approximately three times and has expanded
care to underserved communities, including racial and ethnic minorities. Of the over 8,600
NHSC-approved sites, 46% are community health centers,85 and a large proportion of program
participants go onto practice in this setting.86 In 2008, 2,600 NHSC members served 3.7 million
patients which increased to more than 10,000 providers serving 10.5 million people in 2011.87 The
current NHSC members are a diverse group of clinicians: self-reported estimates show that 13%
are African American, 10% are Hispanic, and 9% are Asian, Pacific Islander, American Indian, or
Alaskan Native. According to 2012 estimates, both African American and Hispanic physicians
made up a larger percentage of physicians in the NHSC workforce than physicians in the general
population (17% versus 6% and 16% versus 5%, respectively).88
Emerging Programs and Models
Data from a 2011 observational study of the NHSC program reveals the benefits of its expansion
and commitment through the ACA. The study reveals that funding ($300 million) provided
through the American Recovery and Reinvestment Act (ARRA) of 2009 to support expansion of
the NHSC fueled the largest growth of clinicians in the NHSC’s history. During the 2-year period,
a 156% increase in clinicians was seen, rising from 3,017 to 7,713. Figure 2 illustrates the percent
increase in number of clinicians by state following the funding expansion.89
43
Figure 2. Map of percentage and numerical growth in National Health Service Corps'
(NHSC) clinicians in each U.S. state during the American Recovery and Reinvestment Act
funding period, March 2009 through February 2011.
Source: Data from the U.S. Bureau of Clinician Recruitment and Service's Management Information System Solution as cited in
Pathman, D. E., & Konrad, T. R. (2012). Growth and Changes in the National Health Service Corps (NHSC) Workforce with the
American Recovery and Reinvestment Act. The Journal of the American Board of Family Medicine, 25(5), 723-733.
Percentage change in clinician growth was also examined among states depending on the preARRA funding ratio of NHSC clinicians to proportion of the population living in poverty. It was
found that states with the lowest number of NHSC clinicians per 100,000 population experienced
highest growth in NHSC clinicians (291%) and states with the highest number of NHSC per
100,000 population experienced the lowest amount of growth (111%) (Table 7).90
Table 7.Percentage Growth in States’ Total National Health Service Corps (NHSC)
Clinician Numbers during the American Recovery and Reinvestment Act Period:
Relationship to Baseline Number of Corps Loan Repayment Clinicians per 100,000
Population Below Poverty
State Quartile at
baseline
States
(n)
States’ baseline
NHSC Clinicians per
100,000 Population
below poverty
States’ Growth in
NHSC Clinicians
During Recovery Act
Period (mean %)
SD
Lowest quartile
Second lowest quartile
Second highest quartile
Highest quartile
All states’ average
13
13
13
12
51
0.63 – 5.36
5.49 – 7.96
8.08 – 14.50
15.78 – 62.92
0.63 – 62.92
291%
210%
172%
111%
197%
253
146
71
67
164
Source: Data from the U.S. Bureau of Clinician Recruitment and Service's Management Information System Solution. as cited
in Pathman, D. E., & Konrad, T. R. (2012). Growth and Changes in the National Health Service Corps (NHSC) Workforce with
the American Recovery and Reinvestment Act. The Journal of the American Board of Family Medicine, 25(5), 723-733.
44
Challenges and Next Steps
Continued investment in the NHSC has proved to be a promising development to better serving
the needs of racially and ethnically diverse populations. Recent analyses reveal important
implications in how significant increases in NHSC funding can shape and grow the workforce,
especially for diverse populations. The data show that the highest growth occurred for states that
had the fewest number of clinicians relative to the size of their low-income populations. This
represents a promising finding in addressing disparities in health care and will be important to
continue tracking as the NHSC experiences further growth under the ACA. However, challenges
for African American NHSC members serving in rural areas have surfaced—these individuals have
historically reported lower satisfaction in both their professional and personal lives. In addition,
minority NHSC physicians in general have cited challenges in site placements, including
placement away from their home states.91 It is unclear whether this challenge is being addressed,
as our literature review has not revealed any more recent analysis of satisfaction among minority
clinicians serving in the NHSC.
Graduate Medical Education
Legislative Context
Section 5503 of the ACA directs the Secretary of HHS, beginning July 1, 2011, to convert unfilled
hospital residency positions under the Graduate Medical Education (GME) program to slots for
primary care physicians. An exception is given to hospitals in rural areas with less than 250 beds.
Preference for redistributing unfilled residency slots is given to states with a low resident
physician-to-population ratio or with large numbers of people living in primary care health
professional shortage areas. Urban hospitals that have accredited rural training programs and
rural programs are also given preference.
Implementation Status and Progress
On November 2, 2010, the Centers for Medicare & Medicaid Services (CMS) issued final
regulations regarding the redistribution of medical resident cap slots from hospitals that were
below their caps to hospitals that applied to CMS for increased slots to expand their residency
programs. This provision requires that 70% of the resident slots be distributed to hospitals in
states ranking among the lowest quartile of resident-to-population ratios, and 30% be distributed
to hospitals located in rural or health profession shortage areas. CMS outlined requirements for
awardees in the 2011 Outpatient Prospective Payment System (OPPS) final rule92 which specifies
that hospitals maintain a certain number of primary care residents based on the number of
resident slots it had before the increase, and also specifies that at least 75% of the newly awarded
slots be used for primary care or general surgery.
CMS announced on August 15, 2011 which teaching hospitals had received changes to their
resident caps. Excess slots were redirected to 58 hospitals—726 direct graduate medical education
(GME) resident slots, and 628 indirect graduate medical education (IME) resident slots, from 267
hospitals were redirected. Five rural hospitals received a cap increase.93
45
Emerging Programs and Models
Table 8 lists the 58 hospitals that received resident cap increases under Section 5503 of the ACA.
The number of IME and GME slots awarded is shown by hospital. In addition, the percent of the
city’s population that is Non-Hispanic White according to the U.S. Census is shown. Table 8
displays, in general, the proportion of diverse cities and metro areas receiving increased GME and
IME slots. Although not a perfect measure of patient racial and ethnic demographics of a
particular hospital, cities with populations made up of less than 50% Non-Hispanic White
residents are highlighted to show the diverse areas that have seen increased opportunities to train
residents, including many in primary care, under this policy change. Twenty-four of the 58
hospitals are located in diverse areas, according to this criterion. The 24 hospitals located in
highly diverse areas—i.e., those with more than 50% Non-Whites—are highlighted in red (Table
8).
Challenges and Next Steps
The disconnect between current primary care challenges and the GME program has surfaced as a
criticism of these federally-funded resident training programs.94 Section 5503 represents a critical
step toward aligning teaching hospitals with current healthcare needs by providing more resident
training opportunities in primary care. However, oversight attached to these funds is still lacking
in terms of the quality of training, performance standards for trainees, and patient outcomes.
Other challenges relate to proposed funding cuts for GME programs. Though Congress has not
acted on either, two proposals emerged after the passage of the ACA, threatening federal funding
for indirect and direct GME payments.95
It has also been noted that the number of slots redistributed to hospitals under this provision,
while largely benefiting medically underserved areas, represents only a fraction of what will be
needed to bridge the gap in health and health care disparities these populations face. As stated by
Len Marquez, the Director of Government Relations at the American Association of Medical
Colleges, “It doesn’t get us anywhere close.”96 Calculations on the projected number of medical
residents trained can be derived by dividing the number of new residency slots by 4, the length in
years of most residency programs. Therefore, as stated succinctly by Marquez, the outcomes of
Section 5503 clearly fall short of what is needed: “At a time when we need to be training an
additional 4,000 a year, we're going to train an additional 200 a year." His organization has
projected a shortage of 91,500 physicians by 2020.97
While this provision specifies that programs receiving increased residency slots must dedicate a
certain number of those to primary care, it should be cautioned that this does not necessarily
indicate that these trainees will go on to practice in primary care. The Council on Graduate
Medical Education (COGME) has recommended that when evaluating shortages in primary care,
successful outcomes should not be measured based on the number of trainees entering primary
care residencies, but rather on where physicians go to practice and train following their
postgraduate medical training. In fact, data from the National Resident Matching Program, as
reported by COGME, indicate that among residents matched to primary care specialties
(including family medicine, internal medicine, and pediatrics), approximately 40% are likely to go
on to practice in primary care.98
46
Table 8. Hospitals awarded increases in IME/GME slots and Percent of Non-Hispanic White by city
Hospital Name
Location
Baptist Medical Center South
Huntsville Hospital
DCH Regional Medical Center
Princeton Baptist
University of South Alabama Children's & Women's Hospital
The George Washington University Hospital
Washington Hospital Center
Children's National Medical Center
Orlando Regional Medical Center
Florida Hospital Orlando
University of Miami Hospital
Medical Center of Daytona Beach
Jackson Memorial Hospital
Sacred Heart Hospital
Mount Sinai Medical Center
Broward General Medical Center
Sylvester Comprehensive Cancer Center/UMHC
Tallahassee Memorial Healthcare
Mayo Clinic Florida
Palmetto General Hospital
Northside Hospital & Tampa Bay Heart Institute
Wellington Regional Medical Center
Westchester General Hospital
Cleveland Clinic in Florida – Weston
Miami Children's Hospital
Saint Luke's Boise Medical Center
West Valley Medical Center
Madison Memorial Hospital
Portneuf Medical Center
Franciscan Saint Francis Health - Beech Grove Campus
Montgomery, AL
Huntsville, AL
Tuscaloosa, AL
Birmingham, AL
Mobile, AL
Washington, DC
Washington, DC
Washington, DC
Orlando, FL
Orlando, FL
Miami, FL
Daytona Beach, FL
Miami, FL
Pensacola, FL
Miami Beach, FL
Fort Lauderdale, FL
Miami, FL
Tallahassee, FL
Jacksonville, FL
Hialeah, FL
Saint Petersburg, FL
Wellington, FL
Miami, FL
Weston, FL
Miami, FL
Boise, ID
Caldwell, ID
Rexburg, ID
Pocatello, ID
Beech Grove, IN
IME Slots
awarded
7.7
25.6
8
11.57
0
7.9
39.58
0
4.58
31.6
2.43
8.67
5.36
3
0.87
16.79
0
39
3.44
20.43
5.11
9
6
5.38
0
3.46
2
2
3.75
0.81
GME slots
awarded
7.7
36.82
8
14.05
8.34
7.9
39.58
12
4.75
37.64
4.36
9.17
9.62
3
0
29.21
1.09
39
7.95
36.66
9.16
9
6
9.66
14
3.46
2
2
3.75
0
% Non-Hispanic
White
36.1%
58%
52.6%
21.1%
43.9%
35.3%
35.3%
35.3%
41.3%
41.3%
11.9%
54.4%
11.9%
64.3%
40.5%
52.5%
11.9%
53.3%
55.1%
4.2%
64.3%
64.8%
11.9%
44.8%
11.9%
85.2%
60.8%
90.8%
86.8%
90%
Indiana University Health Methodist Hospital
Memorial Hospital
Community Hospital East
Saint Vincent Indianapolis Hospital
Indiana University Health Ball Memorial Hospital
Westview Hospital
Baton Rouge General - Mid City
Willis-Knighton Medical Center
East Jefferson General Hospital
Tulane Medical Center
Munson Medical Center
University of Mississippi Medical Center
North Mississippi Medical Center – Tupelo
Billings Clinic Hospital
Saint Vincent Healthcare
Renown Regional Medical Center
University Medical Center
Indianapolis, IN
South Bend, IN
Indianapolis, IN
Indianapolis, IN
Muncie, IN
Indianapolis, IN
Baton Rouge, LA
Shreveport, LA
Metairie, LA
New Orleans, LA
Traverse City, MI
Jackson, MS
Tupelo, MS
Billings, MT
Billings, MT
Reno, NV
Las Vegas, NV
22
3
25.85
18
12
7
18
4
1.83
10.08
0.53
32.57
0.95
18.88
1
21
50.34
22
3
22.67
18
12
7
18
4
1.83
10.08
0.53
32.57
0.76
18.43
1
21
50.34
58.6%
55.8%
58.6%
58.6%
82.8%
58.6%
37.8%
40%
72.4%
30.5%
76.4%
18%
57.7%
86.9%
86.9%
62.5%
47.9%
University of New Mexico Hospital
Memorial Medical Center
Albuquerque, NM
Las Cruces, NM
24.92
2.92
24.92
0
42.1%
37.5%
Medical Center of Southeastern Oklahoma
Robert Packer Hospital
Hospital de la Concepcion
Saint Luke's Memorial Hospital
Durant, OK
Sayre, PA
San German, PR
Ponce, PR
3
1.71
6
20.67
3
0
6
20.67
71.2%
95.1%
0.6%
0.6%
Sistema Integrados De Salud Del Sur Oeste Inc
Avera McKennan Hospital & University Health Center
Mayaguez, PR
Sioux Falls, SD
2.7
3
7.35
3
0.7%
84.9%
Sanford USD Medical Center Sioux Falls
Norton Community Hospital
Saint Joseph's Hospital
Sioux Falls, SD
Norton, VA
Marshfield, WI
21
4.52
16.55
21
4.52
16.55
84.9%
n/a
93.5%
628.05
726.09
Total Pool
Note: Highlighted in red are institutions located in diverse cities (i.e., Non-Hispanic Whites comprise less than 50% of the city’s population) which have seen
increased GME/IME slots. Source: Centers for Medicare & Medicaid Services. Downloads: “Section 5503 Cap Decreases and Increases.” Available at:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/dgme.html and U.S. Census Bureau, QuickFacts, 2010.
48
Area Health Education Center
Legislative Context
Section 5403 of the ACA authorizes funding for grants to Area Health Education Centers (AHECs)
to support community-based training and education in health. Awards are available for both the
development of new health care workforce educational programs as well as to continue or
improve upon existing AHECs. The legislation requires entities to recruit racially and ethnically
diverse or disadvantaged individuals or residents of rural areas and to conduct training and
education for individuals who commit to careers in underserved areas. Under this provision, $125
million were authorized for each FY 2010 through FY 2014.
Implementation Status and Progress
HRSA awarded grants under two programs: the AHEC Infrastructure Development program and
the AHEC Point of Service Maintenance and Enhancement program. Funding actually received
for this provision represented only one-fourth of what was authorized by the ACA each year.
Specifically, as opposed to receiving $125 million each year, $33 million was awarded in FYs 2010
and 2011, each,99 $27 million in FY 2012, and $28 million in FY 2013 (Table 9).100, 101 While funding
for FY 2014 is still uncertain, a total of $75 million have been requested.102
Table 9. Authorized Funding in the ACA and Actual Funding for
Area Health Education Centers (AHEC), FY 2010-2014
FY 2010
AHEC
FY 2011
FY 2012
FY 2013
FY 2014
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Requested
$125 m
$33 m
$125 m
$33 m
$125 m
$27 m
$125 m
$28 m
$125 m
$75 m
Note: Auth = Authorized
Emerging Programs and Models
At least half of the funded AHEC programs explicitly cite in their program descriptions that they
target racially and ethnically diverse communities. The following programs are examples of those
that have outlined goals for recruiting, training, and serving in underserved and diverse settings:
•
The University of North Dakota: The University and its partners are using the new
funding to continue the development of two of its regional centers. The program
continues to promote health professional careers to rural, racially and ethnically diverse
students of all levels through: summer camps and enhanced clinical shadowing
opportunities; the establishment of a Health Occupation Student Association chapter; and
maintained efforts to hold community-based inter-professional trainings in underserved
areas.
•
Montana State University: This grantee is recruiting and supporting programs in
collaboration with its four regional centers for minority, disadvantaged, and rural students
in medicine, nursing, and other health professions to ensure their success. An emphasis is
placed on primary care and public health. Rural field placements will encourage students
to practice in rural areas in the state.
•
Indiana University: The Indiana AHEC Network will support and further enhance
community-academic partnerships for health professions training. The program explicitly
aims to improve the representation of minorities, disadvantaged, rural or otherwise
underserved individuals among health care workers by promoting awareness of health
professions and strengthening academic and readiness skills. The grantee will also focus
on increasing the number of health professions students who will go on to practice in
medically underserved communities by increasing students’ knowledge of the
communities’ needs and improving cultural competency training. Finally, Indiana
University and its network will provide professional development training to providers
serving in rural or disadvantaged communities and target goals in practice improvements
and help to fulfill professional education requirements.
Challenges and Next Steps
The AHECs are uniquely positioned to develop and support a diverse and culturally competent
health care workforce. Through academic-community partnerships, many of these entities are
working to recruit, train, and educate a primary care workforce that is diverse and reflective of the
communities they eventually serve. Strengthening the connection between AHECs and
community health centers is key to improving education and training for professionals in
community-based health care settings.103 However, several challenges stand in the way of these
programs’ success, if not addressed. For example, The University of New Mexico Health Sciences
Center partnered with several community-based entities, including an AHEC, to better connect
the community’s health needs with its services and resources, and described several of the
challenges that surfaced. The institution’s faculty in some cases expressed discomfort in
participating in initiatives emphasizing the underlying social determinants of health, as they felt
they were better addressed by other disciplines such as social work, health policy, or public
health. Competing priorities among academic institutions—ranging from hospital beds being
filled to overcrowded emergency departments—were also described as pressing issues for
academic health centers which can distract leaders from recognizing urgent health needs within
the community. In addition, community needs did not always sync with the AHEC’s greatest
strengths (such as specialty services, current research interests and agendas, and educational
programs).104
50
C. Cultural Competency Education and Training
Background
Persons of color are more likely to report experiencing poorer quality and less satisfaction with
patient-provider interactions than Whites, a disparity which is particularly pronounced among
individuals whose primary language is other than English.105 Cultural competence training and
education for health professionals has gained credibility as a strategy for improving the quality of
care delivered to culturally and linguistically diverse patients.106
Cultural competence is defined as:
a set of congruent behaviors, attitudes, and policies that come together in a system,
agency, or among professionals that enables effective work in cross-cultural situations.
‘Culture’ refers to integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values, and institutions of racial,
ethnic, religious, or social groups. ‘Competence’ implies having the capacity to function
effectively as an individual and an organization within the context of the cultural beliefs,
behaviors, and needs presented by consumers and their communities. (Adapted from
107
Cross, 1989).
There is considerable evidence that cultural competency training improves intermediate
outcomes such as knowledge, attitudes, and skills of health professionals along with patientprovider interactions and patient satisfaction.108 Two landmark reports issued by the Institute of
Medicine—Crossing the Quality Chasm and Unequal Treatment—particularly highlight the
importance and promise of cultural competence in improving quality and eliminating racial and
ethnic disparities in health care. In addition, cultural competence at the organizational level can
assist in deinstitutionalizing racism and guiding culturally competent program development and
evaluation.
Despite the thrust to advance cultural competence, however, few published studies link such
training to improved health outcomes.109,110 There is also considerable lack of consensus about
effective education and training programs and approaches for teaching cultural competence.111
Provisions in the Affordable Care Act (ACA) which aim to explicitly advance cultural competency
education and training in the health care fields thus offer an important opportunity not only to
improve quality, satisfaction, and outcomes among diverse patients, but to establish a base of
effective curricula through rigorous research, testing, and evaluation. Following are actions the
ACA supports to explicitly improve the cultural competence of health care providers:
•
•
•
Section 4305. Advancing research and treatment for pain care management;
Section 5307. Cultural competency, prevention, and public health and individuals with
disabilities training; and
Section 5507. Demonstration projects to address health professions workforce needs.
While modest, these efforts offer significant potential for improving the cultural competency of
providers in areas of health care where disparities are entrenched. Studies show that Non-White
racially and ethnically diverse patients frequently receive suboptimal care for pain management
and are at high risk for poor pain outcomes.112,113 For example, in a study for analgesia therapy,
Hispanics were twice as likely not to receive pain medication than Non-Hispanic Whites.114 Blacks
51
also experienced similar outcomes. Patient education, as well as physician education, is an
important part of pain management. Disparities also exist in home care outcomes for diverse
patients. A recent study found that racial and ethnic minorities experienced substantially worse
functional outcomes than did Non-Hispanic White home health care recipients, and this disparity
was most pronounced between Whites and African Americans.115 Part of the problem is a lack of
cohesive standards and training requirements, particularly in established core competencies,
including cultural competency.
Section 5407 offers a unique opportunity to test the impact of cultural competency training
programs across a range of health professions and identify successful models for improving both
process and health outcomes. It also offers an opportunity to assess efficacy (i.e., does it work?)
and effectiveness (i.e., how well does it work?) of training and education programs, which is
largely lacking in the field of cultural competence. A national clearinghouse on validated cultural
competence measures, assessments, curricula, and other tools could help to create cohesion and
consensus, as well as offer a real-time portal for exchanging information, lessons learned, and best
practices. The online clearinghouse could also provide a forum for discussion of new and
innovative efforts.
The narrative that follows discusses these three provisions in detail, describing their progress in
implementation along with challenges and steps that lie ahead for their full realization.
Cultural Competency in Pain Care
Legislative Context
Section 4305 authorizes research, treatment, and education to further enhance and improve pain
care management. The law specifically charges the National Institutes of Health (NIH) to
continue and expand, through the Pain Consortium, an aggressive program of basic and clinical
research on the causes of and potential treatments for pain. In addition, the ACA authorizes
HRSA to establish a new grants program for health professional schools, hospices, and other
public and private entities for the development and implementation of programs to provide
education and training to health care professionals in the diagnosis, treatment, and management
of acute or chronic pain. An explicit requirement of the award is that the applicant includes
information and education on cultural, linguistic, literacy, geographic, and other barriers to care
in underserved populations. Such sums as necessary are authorized for this grant program for FY
2010 to FY 2012.
Implementation Status and Progress
To date, the new HRSA grants program to provide health professionals with education and
training in pain care has not received funding under the ACA. However, the provision of the law
that charges the NIH with expanding and enhancing research topics related to the diagnosis,
treatment, and management of pain has moved forward. The Institute of Medicine’s (IOM)
Committee on Advancing Pain Research, Care, and Education held five meetings between
November 22, 2010 and April 19, 2011 to address the following priorities:
•
•
•
Assess the public health impact of pain;
Review research, care, and education related to pain; and
Identify barriers in pain care.
52
On June 29, 2011 the committee publicly released the resulting report titled Relieving Pain in
America: A Blueprint for Transforming Prevention, Care, Education, and Research. The report
highlights several aspects of racial and ethnic disparities in pain care. For example, in recognizing
pain as a public health challenge, the report reviews current evidence which reveals that certain
subgroups, including racially, ethnically, and linguistically diverse populations, experience pain at
a higher rate and are more likely to receive inadequate treatment for their pain. The authors also
point out a challenge to evaluating pain among different populations is variation in how data are
collected and reported on pain across various population groups. Furthermore, while there is a
general consensus that pain is undertreated among different groups, the phenomenon remains
poorly understood due to the lack of comprehensive and systematic research studies exploring
the issue. The report reviews current evidence among African American, Hispanic, Asian, and
American Indian or Alaska Native populations to highlight documented challenges these groups
face in receiving pain treatment.
The report further developed a comprehensive action plan and specific recommendations in order
to improve the state of pain research, education, care, and prevention. Priority recommendations
include creating a comprehensive pain strategy, developing strategies to eliminate barriers to
care, ensuring better collaboration among pain specialists and primary care physicians, and
identifying a lead institute at the NIH tasked with advancing research in pain care. Authors also
stated that “enhanced continuing education and training are needed for health care professionals
to address gaps in knowledge and competencies related to pain assessment and management,
cultural attitudes about pain.”116
Emerging Programs and Models
The NIH recognized health disparities in pain care as a research priority after releasing its 2011
request for new priorities for advancing pain research.117 As stated in the FOA, the following
research questions were identified as priorities under the health disparities topic area:
•
•
•
•
•
•
Differences in care for various types of pain, acute postoperative pain, treatment-related
pain, cancer pain, or chronic non-malignant pain, in various settings (i.e., health clinics,
physician and dental offices, institutional settings including long-term care facilities,
assisted living facilities, or emergency departments), and management of pain at the end
of life.
Differences in the factors contributing to pain disparities including patient-related (e.g.,
communication, attitudes), health care provider-related (e.g., decision making), and
health care system-related (e.g., access to pain medication) factors.
Differences in perceptions of pain and responses to pain and how these differences impact
appropriate treatment and management of pain.
The nature and extent of disparities in the delivery of pain treatment in diverse
populations.
Existing and potential barriers to quality pain care and management including patientrelated barriers, health care provider-related barriers, health care system-related barriers,
and sociocultural barriers.
Novel, evidence-based interventions to improve training for health care providers and
educational interventions for minority patients.
53
•
•
•
•
•
•
•
•
Measures of pain perception for those with cognitive impairment, or limited health
literacy and from varied cultures.
Assessment of the global impact, including societal and medical consequences, of pain
related disparities on both individuals and society, and the potential impact of painrelated disability.
Diverse cultural beliefs about and actions taken for pain and its management including
self-care and that of lay caregivers.
Treatment and management strategies for chronic pain in diverse populations.
Means to identify population differences in pain perception and processing by addressing
the incidence, severity, and consequences of pain in these and the general populations,
and in specific disease states.
New diagnostic tools for different pain mechanisms, and objective measures of treatment
response that have validity in diverse populations.
The prevalence and effectiveness of the use of non-pharmacological and novel (e.g. virtual
reality) therapies for pain treatment in diverse populations such as ethnic minority groups
and persons with disabilities.
Pain management for special populations including infants, children, elderly, cognitively
impaired, disabled, chronically and/or terminally ill, and patients with psychiatric
diagnoses.118
Twelve health professional schools were identified as Centers of Excellence in Pain Education
(CoEPEs) by the NIH Pain Consortium. These include:
•
•
•
•
•
•
•
•
•
•
•
•
University of Washington, Seattle;
Johns Hopkins University, Baltimore;
University of Pennsylvania Perelman School of Medicine, Philadelphia;
Southern Illinois University, Edwardsville;
University of Rochester, N.Y.;
University of New Mexico, Albuquerque;
Harvard School of Dental Medicine, Boston;
University of Alabama at Birmingham;
Thomas Jefferson University School of Medicine, Philadelphia;
University of California, San Francisco;
University of Maryland, Baltimore; and
University of Pittsburgh.
These centers are improving upon education for medical, dental, nursing, and pharmacy students
regarding pain and pain management and will serve as central repositories for curriculum
resources.119 Curriculum development will include a focus on how pain manifests across different
groups, including racially and ethnically diverse populations.120 In July 2012, a kickoff event and
reception was held for participating centers and an introduction to the initiative was provided.
Topics addressed included the type of education material to be available in the pain portal and
effective efforts to incite a cultural change in pain care among health care professionals.121 The
most recent activity identified is the ongoing discussion on case studies that the Centers of
Excellence will use in developing educational materials.122 As these materials are being developed
and disseminated, it will be important to continue tracking and monitoring progress in the
Consortium’s efforts to achieve goals in health equity.
54
Challenges and Next Steps
Studies show that physicians-in-training often do not receive any formal education in pain
management during medical school or residency training.123 In addition, there is little consensus
or cohesiveness on national guidelines on pain management. There are currently different
standards and recommendations endorsed by various professional associations for dispensing
opiates and other narcotics which complicates appropriate management.124 Effective care for pain
patients, including those who are racially and ethnically diverse, has been slowed by the absence
of clear national treatment priorities and guidelines. Evidence shows that having significant
knowledge in recognizing, assessing, and treating pain appropriately is fundamental to
diminishing inconsistencies in pain management among various racial and ethnic groups.125
Cultural Competency in Geriatric and Long Term Care
Legislative Context
Section 5507 authorizes grants for new demonstration projects to develop core training
competencies and certification programs for personal or home care aides. Competencies related
to provider communication are outlined within this Section, including “cultural and linguistic
competence and sensitivity,” problem solving, behavior management, and relationship skills. The
request for proposals to establish demonstration projects stated: “Specific project outcome
measures should quantitatively and qualitatively assess the degree to which the intervention
increases the availability of culturally competent personal and home care aides who demonstrate
the skills and attitudes necessary to improve patient health outcomes and reduce health
disparities.”126 The law authorizes $5 million for each FY 2010 to FY 2012 for these demonstration
projects.
Implementation Status and Progress
In September 2010, HRSA awarded grants to six states (Massachusetts, California, Iowa, Michigan,
North Carolina, and Maine) under the Personal and Home Care Aide State Training (PHCAST)
Grant Program of the ACA. Grants aim to strengthen the direct care workforce by defining core
competencies for direct care workers and supporting training development to further improve the
standardization of such competencies. Table 10 illustrates the authorized amount under this
provision and the actual amount funded to states for FYs 2010 to 2012.
Table 10. Authorized Funding in the ACA and Actual Funding for Personal and Home Care
Aide State Training, FYs 2010-2012
FY 2010
PHCAST
FY 2011
FY 2012
Auth.
Actual
Auth.
Actual
Auth.
Actual
$5 m
$4.2 m
$5 m
$4.4 m
$5 m
$4.4 m
Note: Auth = Authorized
55
Emerging Programs and Models
The PHCAST Report to Congress on Initial Implementation reveals that all funded states are
moving forward to meeting outlined goals. The majority have met with stakeholder groups to
achieve buy-in from each group’s respective direct care worker sector. Most funded states are also
reaching out to professional associations for curricula development and trainee recruitment
efforts. In order to target a diverse population during recruitment, states are also partnering with
community colleges, current employers of direct care workers as well as workforce investment
boards. All states appear to have made progress toward addressing the required competency of
“understanding diversity and cultural competence.”127 Maine has identified a refugee population
for outreach efforts. Massachusetts and California are focusing trainings in underserved
populations, among individuals who have incomes at or below 200% of the federal poverty level,
and are displaced workers or make up the working poor. California has developed a training
competency to include goals related to English as a second language for its trainees.
Challenges and Next Steps
According to the same report, grantees face similar challenges in implementing the PHCAST
program. A frequent barrier cited was short time requirements for curricula development and
evaluation. All states felt it was important to involve a broad group of stakeholders, but this
delayed the competency approval process. States also found that definitions and terminology
varied among groups so additional time was spent to ensure standard definitions were used
during curricula development. Similarly, roles and responsibilities of different direct care workers
(Personal Care Aide vs. Home Care Aide) were still unclear and required addressing. Grantees are
required to develop a certification process and this was also cited as a challenge across states.
States have found that costs related to certification may become a roadblock to recruitment as
states frequently reach out to individuals from underserved and disadvantaged backgrounds,
including diverse populations. 128
Model Cultural Competency Curricala
Legislative Context
Section 5307 of the ACA amends section 741 of the Public Health Service Act and authorizes a
grants program for the purpose of the development, evaluation, and dissemination of research,
demonstration projects, and model curricula for cultural competency, prevention, public health
proficiency, reducing health disparities and aptitude for working with individuals with
disabilities. Model curricula developed under this section will be disseminated through the
Internet Clearinghouse under Section 270. The legislation also amends Section 807 of the Public
Health Service Act to establish the same program for nursing curricula. The law authorizes such
sums as necessary for each FY 2010 to FY 2015.
Implementation Status and Progress
As of this writing, this provision has not received funding under the ACA.
56
Emerging Programs and Models
At least six states (Washington, California, Connecticut, Maryland, New Jersey, and New Mexico)
have enacted legislation which requires or strongly recommends cultural competency training for
health care providers (see Figure 3). In states such as California, Washington, and New Jersey,
these laws set standards and expectations for providers, clinics, and other health related services.
Figure 3. Cultural Competency Legislation by State, 2012
States in blue are those with enacted cultural competency legislation; states in red had
legislation that was referred to committee and/or is currently under consideration; and states
in yellow denote legislation that died in committee or was vetoed.
In 2005, New Jersey became the first state to enact legislation requiring medical professionals to
receive cultural competency training in order to receive licensure or re-licensure. To facilitate this
training, the state required that each medical school in New Jersey provide cultural competency
instruction focused on “race and gender-based disparities in medical treatment decisions”
through classroom instruction or other educational programs, including continuing education
credit.129 Other states, including Illinois, New York, and Arizona are addressing the issue by
funding programs and initiatives to provide cultural competency training in addition to
considering policy-level actions.
At the federal level, HRSA has played a leading role in supporting health professions education,
training and resources on cultural competence well before passage of the ACA. Examples include:
(1) offering clinical training videos on quality care for diverse populations; (2) courses on cultural
and linguistic competence in diagnosis and treatment of depression; (3) cultural competence
curricula enhancement modules; (4) cultural and linguistic competence education programs
through its Centers of Excellence; (5) diversity in dentistry and medicine programs; (6) cultural
competency in geriatric programs; among other efforts. HRSA also offers a series of web-based
trainings through its grantees. These include, for example, online training on cross-cultural
communication and building organizational diversity and capacity. The National Center for
57
Cultural Competence (NCCC), a major grantee of HRSA, offers a web-based portal of information,
resources and best practices.130
Finally, the federal Office of Minority Health has also played an important role in advancing the
field of cultural competence. Among its major efforts are:
•
Enhanced National Standards on Culturally and Linguistically Appropriate
Services, also referred to as “CLAS Standards” and originally issued in 2000, with updates
released in 2013, explicitly provide a framework for health professionals and organizations
to effectively and appropriately serve patients from diverse backgrounds. “The CLAS
Standards are a collective set of mandates, guidelines, and recommendations intended to
inform, guide, and facilitate required and recommended practices related to culturally and
linguistically appropriate health services. The CLAS Standards provide guidance on
improving quality care under three areas in particular: Culturally Competent Care,
Language Access Services and Organizational Supports.”131
•
Think Cultural Health is a Web-based portal which offers the latest resources and tools
to promote cultural and linguistic competency in health care.132 It features free and
accredited continuing education programs targeting physicians, nurses, and other health
professionals. Among its recognized tools are: “A Physician’s Practical Guide to Culturally
Competent Care” targeting physicians, physician assistants, and nurse practitioners133, and
“Culturally Competent Nursing Care: A Cornerstone of Caring” accredited for nurses and
social workers.134
Challenges and Next Steps
While provisions in the ACA reflect a modest commitment to addressing cultural competence
through federal initiatives, questions remain regarding the extent to which these efforts will be
embraced. As it is, funding for two out of three initiatives was not appropriated. This limitation
may be compounded by challenges at the organization and practitioner level. At the organization
level, there is still considerable reluctance to make a concerted effort to invest in and address
cultural competence, despite its proven benefits. In a survey of 82 urban academic institutions
participating in a collaborative aimed at developing a more diverse and prepared workforce, it was
found that goals around diversity and cultural competency were present in the strategic plans of
essentially all the universities. However, many schools were not prepared to collect the
appropriate data to measure progress, and despite having innovative programs in place, they were
unable to reliably report on progress made.135 At the practitioner level, time-strapped health care
professionals may be reluctant to participate in cultural competency training or to use Web-based
education materials unless they are provided with financial incentives or continuing education
credits. Moreover, without model development and related assessment—including
documentation of effects on processes and outcomes of care—questions will continue to arise
about what works and the value of investment in time, money, and staff.
58
D. Health Care Workforce Evaluation and Assessment
Background
The scarcity of research, data, and information describing current and future workforce capacity
and shortages is a well-recognized challenge to developing effective healthcare workforce policy.
As the ACA’s coverage expansions and novel practice models are implemented, it is critical to
gather and learn from concrete workforce data and analysis in order to make informed and
accurate decisions about healthcare workforce needs and challenges. This is especially critical for
the health status of racially and ethnically diverse populations as they will make up a large
percentage of the newly insured.136 In this section, we highlight two important provisions that
support improved mechanisms to evaluate and assess workforce needs, including the needs of
diverse populations:
•
•
5101. National health care workforce commission; and
5102. State health care workforce development grants.
In 2007, the Council on Graduate Medical Education recommended the creation of a National
Health Care Workforce Commission to make recommendations to Congress on workforce issues
such as the number of Graduate Medical Education (GME) positions, payment rates for such
positions, and future research priorities.137 The ACA creates such a commission for the first time,
and also provides funding and support for states to project, plan for, and address workforce
demands within the state as the healthcare landscape changes under the ACA.
National Health Care Workforce Commission
Legislative Context
Provision 5101 authorizes the establishment of a new entity, the National Healthcare Workforce
Commission. The Commission is charged with coordinating healthcare workforce activities across
federal agencies, evaluating workforce demands and education needs, identifying and proposing
solutions to current and future workforce challenges, and supporting novel programs to improve
upon health care professions education. The Commission’s goal is to present recommendations to
Congress and the President regarding the synchronization of healthcare workforce priorities and
the nation’s needs. The law specifies that special topics to be reviewed include: “the health care
workforce needs of special populations, such as minorities, rural populations, medically
underserved populations, gender specific needs, individuals with disabilities, and geriatric and
pediatric populations with recommendations for new and existing Federal policies to meet the
needs of these special populations.” Such sums as necessary are authorized to be appropriated for
this section.
Implementation Status and Progress
On September 30, 2010, the Comptroller General of the Government Accounting Office
announced Commission nominations. To date, Congress has not appropriated funding for this
provision, so while the 15 Commission members have been announced, they have not been able to
59
meet or conduct business due to lack of funding. The appointments of the first 15 members are
staggered at one, two, and three years (Table 11).
Table 11: Members of the National Healthcare Workforce Commission
Term Expiring in 2013
Peter Buerhaus, PhD, RN (CHAIR)
Sheldon Retchin, MD, MSPH (VICE
CHAIR)
Brian J. Isetts, PhD
Harold M. Maurer, MD
Thomas Ricketts, PhD
Professor of Nursing and Director, Center for Interdisciplinary Health
Workforce Studies, Institute for Medicine and Public Health,
Vanderbilt University Medical Center
Vice President for Health Sciences, Virginia Commonwealth
University and Chief Executive Officer, VCU Health System.
Professor, Department of Pharmaceutical Care and Health Systems,
University of Minnesota College of Pharmacy
Chancellor, University of Nebraska Medical Center
Professor, Department of Health Policy and Management, University
of North Carolina Gillings School of Global Public Health, and Deputy
Director for Policy Analysis, Cecil G. Sheps Center for Health Services
Research.
Term Expiring in 2012
Mary Mincer Hansen, RN, PhD
Director, Masters in Public Health Program, College of Health
Sciences, Des Moines University
John E. Maupin, Jr., DDS
President, Morehouse School of Medicine
Neil M. Meltzer, MPH
President and Chief Operating Officer, Sinai Hospital, Baltimore, MD
Fitzhugh Mullan, MD
Professor of Public Health and Pediatrics, George Washington
University
Steven Zatkin, JD
consultant to health plans
Term Expiring in 2011
Katherine A. Flores, MD
Kim Gillan
Director of the University of California (UCSF) Fresno Latino Center
for Medical Education and Research
Workforce Development and Training Coordinator, Montana State
University’s Billings (MSUB) College of Professional Studies and
Lifelong Learning
Lisa Renee Holderby
Director of Health Equity, Community Catalyst
Deborah King
Executive Director, 1199SEIU Training and Employment Funds
Richard Krugman, MD
Vice Chancellor for Health Affairs, University of Colorado Denver and
Dean, University of Colorado School of Medicine
Source: Press release: GAO announces appointments to new National Health Care Workforce Commission. September
30, 2010. The U.S. Government Accountability Office. Available at: http://www.gao.gov/press/nhcwc_2010sep30.html
Emerging Programs and Models
In the absence of a current national model for a comprehensive commission addressing workforce
planning, development, and advocacy, helpful guidelines and practices can be gleaned from statelevel initiatives. California is among states leading in workforce planning and development.
Several entities collaborate as part of the Healthcare Workforce Development Division (HWDD)
under the Office of Statewide Health Planning and Development. HWDD promotes diversity in
California’s health care workforce by supporting underrepresented demographic groups in their
60
pursuit of careers in health care as well as advocating for more primary care practitioners in
California’s health professional shortage areas.138 Its 15-member California Healthcare Workforce
Policy Commission (CHWPC), authorized under the Health Care Workforce Training Act, is
charged with, among other duties, evaluating and identifying geographic areas in California where
healthcare resources are poorly distributed and have high unmet healthcare needs.139 It also
houses the California Healthcare Workforce Clearinghouse, authorized by Senate Bill 139, which
collects and stores publically available health workforce data.
In addition to the state’s previously established planning efforts, in 2010 California’s Health
Workforce Development Council was formed to conduct workforce planning as a special
committee of the California Workforce Investment Board. After convening 11 regional focus
groups throughout the state, the Council developed a series of recommendations in 10 topic areas,
many of which explicitly address the elimination of health disparities including:140
•
•
•
•
Incentivize the education/training admissions process for applicants from diverse
populations;
Provide incentives to attract diverse students to primary care roles;
Mandate cultural sensitivity training for health professionals (e.g. Culturally and
Linguistically Appropriate Service Standards);
Increase engagement in cross-cultural opportunities for health care organizations and
education/training institutions.
The Council has since developed action plans and ad hoc committees to implement the report’s
recommendations which are currently in progress.
Challenges and Next Steps
The National Healthcare Workforce Commission’s lack of budget to conduct operations has
dismal implications for workforce planning and policy development that is currently needed at a
national level. The current issue of disjointed workforce data and research is likely to persist,
challenging workforce policy development under new health care delivery models. Furthermore,
questions related to the presence and extent of health care disparities across different regions may
remain unanswered. Current groups, such as the Medicare Payment Advisory Commission and
the Centers for Medicare and Medicaid Services have the authority to make narrow
recommendations related to payment policies and changes to regulations, but there is no group
that can provide the broad and comprehensive guidance necessary for national workforce
planning and development.141
State Health Care Workforce Development Grants
Legislative Context
Section 5102 of the ACA establishes a competitive, HRSA-administered grant program, referred to
as State Health Care Workforce Development Grants. The program is to award 1-year planning
grants of up to $150,000 with a 15% matching requirement to state workforce investment boards.
Grants are to be used for the following types of activities, among others:
• Analysis of state labor markets;
61
•
•
•
Identification of high-demand health care sectors;
Identification of current resources for recruiting, training, and retaining a high quality
health care workforce; and
Identification of state and federal policies and barriers related to developing an allencompassing workforce strategy.
Competitive 2-year implementation grants are also authorized, and the National Healthcare
Workforce Commission, as outlined in Section 5101, is charged with making recommendations on
grant recipients and reviewing the implementation progress reports. While the law does not
include language that explicitly addresses the needs and priorities of racially and ethnically
diverse populations, implications for these populations consistently emerge in developing,
planning, and implementing goals to create a healthcare workforce that adequately represents
and cares for the entire population.
Implementation Status and Progress
On September 27, 2010, HHS Secretary Sebelius announced that 26 states would receive grants
under the ACA to enhance the nation’s primary care workforce through workforce planning and
implementation. Twenty-five states were awarded planning grants and one state received an
implementation grant. Table 12 outlines the authorized funding amount as specified in the ACA
and the actual awarded amount for FYs 2010-2013. In FY 2010, $6 million from the Prevention and
Public Health Fund were awarded to implement the HRSA grants. Such sums as necessary were
authorized for the following years and no further funding has been appropriated.
Table 12. Authorized and appropriated funding for State Health Workforce Development
Grants, FY 2010-2013
FY 2010
Auth.
Planning Grants
Implementation
Grants
Actual
$8 m
FY 2011
FY 2012
FY 2013
Auth.
Actual
Auth.
Actual
Auth.
Actual
SSAN
$0 m
SSAN
$0 m
SSAN
$0 m
SSAN
$0 m
SSAN
$0 m
SSAN
$0 m
$6 m
$150 m
Note: Auth = Authorized; SSAN = Such Sums as Necessary
Emerging Programs and Models
The overall goal described by grantees is to gather data and information for planning activities to
create a comprehensive plan to address health care workforce shortages. A variety of efforts are
described to achieve this goal, and some include initiatives not only to increase the primary care
workforce but also to shape its development through appropriate composition and education. A
review of planning grant program descriptions reveals that all states describe goals to develop
action plans that will: (1) improve upon workforce data collection; (2) align career planning and
education with current health care occupations needs and priorities; and (3) create specific plans
for high-demand occupations. Of the 25 grantees, eight outline explicit goals with a focus on
immigrants, diverse, or vulnerable populations, or to reduce health disparities. Virginia, the single
implementation grantee, describes goals related to cultural competence in its plan to carry out
current workforce planning objectives. The following grantees stand out as examples of states
62
addressing the needs of an increasingly diverse population in workforce development efforts:
•
Hawaii: The planning grant is intended to serve the state’s entire population with a
special focus on ensuring adequate primary care for those residing in isolated areas
such as the neighboring islands. The project description identifies the need to plan
for the state’s diverse populations which include indigenous groups, Native
Hawaiians, the medically underserved, immigrants as well as individuals from U.S.
territories and Pacific Islander protectorates.
•
Colorado: The state has used the planning grant to identify current labor market
needs in order to develop appropriate health care career pathways and to identify
policies and best practices in secondary and postsecondary education and training,
among other activities. In planning for expansion of the state’s primary care
workforce, this grantee highlights its effort to address health disparities by planning
for the state’s vulnerable populations, including those who are underserved and have
been afflicted by poor access to health care services.
•
North Dakota: In its planning grant, the state recognizes the imperative to fully
address infrastructure changes created by the ACA. This includes the need to serve a
population that is increasingly racially, ethnically, linguistically, and culturally
diverse. The state’s program description identifies the need to adequately deliver care
that is both efficient and accessible for these populations when creating its plan to
build, train, and enhance its health care workforce. The state has involved groups
such as state associations, educators, and tribal governments in developing its plan.
•
Virginia: Implementation funding under the ACA supports collaboration between
Virginia’s Health Workforce Development Authority and several state entities and
bodies such as the Department of Health, the state’s Workforce Council, the Area
Health Education Center Program, and the Health Workforce Incentive Program.
Funding has allowed for increased staffing for the Health Workforce Authority, the
creation of an ad hoc committee under the Workforce Council as well as the
implementation of regional data pilot projects. In carrying out these workforce
programs, the state intends to improve both the distribution and composition of its
health care workforce. Culturally and linguistically competent care is being provided
in the state’s most underserved areas through the development of a health
professions pipeline that educates, recruits, and retains diverse healthcare workers.
•
Maryland: The state’s workforce investment board has collaborated with the Hilltop
Institute at the University of Maryland to create its action plan under the ACAfunded planning grant. The Institute is nationally-recognized for its efforts in
addressing disparities. In November of 2011, Maryland’s Workforce Investment Board
released its report based on the findings from the HRSA-funded 1-year planning
grant.142 The report is intended for the Governor’s Health Care Reform Coordinating
Council (HRCC) as well as the numerous organizations, agencies, and stakeholders
committed to enhancing the state’s workforce goals. The action plan was developed
with recognition of the HRCC’s goal to guarantee access to health care to all of the
state’s residents. In an evaluation of the state’s health care workforce needs, increased
attention was given to special populations. Among these are the newly insured who
63
will require more intensive support in enrollment and may face barriers such as
limited English proficiency, poor health literacy, and low education levels. The board
proposed solutions such as a focus on recruiting health providers from underserved
areas to provide needed services to residents of these areas. In addition, team
approaches to providing health care services, mobile health clinics, and community
health workers were other proposed strategies to addressing the needs of vulnerable,
diverse, and medically underserved communities.
Maryland’s investment board has developed 4 strategic goals based on its needs
assessment, and sub-objectives are identified for implementation through 2014. The
first strategic goal involves undertaking in-depth workforce planning and analysis
including ensuring improved data collection efforts to better understand current
workforce capacity and future needs. Among the sub-objectives is a call to report on
the diversity of primary care providers and health professions students. Secondly, the
action plan identifies the strategic goal of strengthening the capacity of the primary
care workforce which includes more specific attention to increasing its racial and
ethnic makeup and enhancing cultural competency. The third strategic goal describes
improving the distribution of the workforce in service shortage areas and includes
reference to developing “creative solutions” to improve the number of health
professionals serving in these regions. The final strategic goal addresses
compensating providers for high quality care where the board will continue to
evaluate strategies to grow Maryland’s Patient-Centered Medical Home initiatives,
which is a promising practice model for diverse and underserved populations.143
Challenges and Next Steps
The workforce planning and implementation grants are a crucial first step in addressing the need
to plan for a workforce that adequately represents our nation’s population and is inclusive of
those who are diverse in race, ethnicity, language, and culture. States receiving the 26 grants
funded under the ACA have made progress toward this goal. They have initiated important
planning activities, created enhanced collaborations with other state entities, and have produced
action plans and next steps to meet workforce goals. There are, however, several challenges that
these states face in fully implementing workforce evaluation efforts. For example, the amount of
funding awarded under this provision was significantly less than the amount authorized
according to the law, especially for the 2-year implementation grants. While $150 million was
authorized in 2010 for such grants, only one state received a grant in the amount of nearly $2
million. The ACA designated the National Healthcare Workforce Commission to recommend
which states receive 2-year implementation grants, however, we found that no such actions have
taken place as the Commission has not received any funding to date to conduct business.
States are generally leading the way in assessing and addressing workforce needs. States such as
Maryland, California, and Virginia, among others, have recognized the importance of planning for
diverse populations, who will represent nearly half of the newly insured once Medicaid
expansions and the exchanges take effect. However, in order to fully realize the goals developed in
their action plans, states will require support at various levels—federal, philanthropic, business,
and other sources. State workforce investment boards will need continued support including
future funding to carry out planning and implementation goals as well as guidance from a
coordinating body such as the unfunded National HealthCare Workforce Commission.
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E. Health Care Workforce Investment in Academic Settings
Background
Initiatives to improve upon minority enrollment implemented at the college and graduate level of
education have shown promising results in increasing diversity in the health professions.144 In
particular, investments Historically Black Colleges and Universities (HBCUs) have made
meaningful contributions to educate and train a cadre of African Americans in professional fields.
As expressed in a 2012 American Journal of Public Health report on HBCUs and the health care
workforce:
The 105 HBCUs in this country are a significant and underused resource in the effort to achieve
health equity. HBCUs have played an important role in the education of people of color for more
than 150 years. During the last quarter of the 20th century, their role was questioned, and the
number of African American students in traditionally White institutions increased dramatically.
During the first decade of the 21st century, however, student enrollment in HBCUs increased, along
145
with the number and variety of degrees they pursued.
Another program which explicitly focuses on enhancing opportunities for underrepresented
minority students and faculty is the Centers of Excellence initiative—a federally funded program
administered by HRSA’s Bureau of Health Professions and originally authorized under Title VII of
the Public Health Service Act. Organizations, such as Hispanics in Health Professions, have
recommended that this program should be better supported and expanded in order to meet broad
goals in diversity for health professions schools.146
The ACA includes provisions intended to support and strengthen these and other programs at
academic settings to ensure the health care workforce is more reflective of the nation’s patients
and population. This section describes the implementation progress, challenges, and next steps
for the following three provisions:
•
•
•
Section 2103. Investment in HBCUs and minority-serving institutions;
Section 5401. Centers for Excellence initiative; and
Section 5402. Health care professions training for diversity.
Historically Black Colleges and Universities & Minority-Serving Institutions
Legislative Context
Section 2103 of the accompanying Health Education and Reconciliation Bill amends the Higher
Education Act by extending the authority to award funding to HBCUs and other minority-serving
institutions through 2019. Mandatory funding for FYs 2008 through 2019 is available in the
amount of $255 million. Of this amount, $100 million is designated for Hispanic Serving
Institutions, $85 million for HBCUs, $15 million for Predominantly Black Institutions, $30 million
for Tribal Colleges and Universities, $15 million for Alaska and Hawaiian Native Institutions, $5
million for Asian American and Pacific Islander Institutions, and $5 million for Native American
non-tribal serving institutions.
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Implementation Status and Progress
The federal government began providing mandatory funding through the ACA to HBCUs and
other minority colleges as of FY 2010.
Emerging Programs and Models
While HBCUs comprise only 3% of the nation’s higher education facilities, they graduate
approximately 28% of African Americans with bachelor’s degrees.147 HBCUs are also the top
producers of African American physicians.148 African American students report benefiting from
the unique experience of attending an HBCU—small class sizes, personal relationships with
faculty members, and fewer experiences with racial tensions, stand out as positive features of
these students’ education.149 Beyond HBCUs are other ethnic and minority-serving institutions
such as those which disproportionately train and educate Hispanics (at least 25% of the full-time
student body is Hispanic), also known as Hispanic Serving Institutions.
Challenges and Next Steps
In recent years, HBCUs and other minority-serving institutions are increasingly being overlooked
as a valuable training resource, with declining or limited support. As a recent study illuminated,
overall between 2000 and 2008, HBCU’s progress in training African American health
professionals did not change.150 Tables 13 - 15 illustrate key findings related to the proportion of
health professional degrees conferred by HBCUs, the number of health professional degrees
awarded to African Americans, and the percentage of African Americans obtaining degrees in
health professions.
Table 13. Proportion of All Health Professional Degrees
Conferred by HBCUs, 2000 and 2008
Discipline
Medicine
Dentistry
Nursing
Public Health
2000
1.40%
2.83%
2.04%
2.26%
2008
1.37%
2.5%
1.66%
1.57%
Percent Change
-.03%
-.33%
-.38%
-.69%
Source: Noonan, A., Lindong, I., & Jaitley, V. N. (2012). The Role of Historically Black
Colleges and Universities in Training the Health Care Workforce. American Journal of
Public Health, Vol 103, No 3.
Table 14. Number of Health Professions Degrees
Awarded to African Americans, 2000 and 2008
Discipline
Medicine
Dentistry
Nursing
Pharmacy
Public Health
2000
1,013
186
7,760
557
820
2008
1,101
203
13,993
775
1,859
Percent Change
+8.69%
+9.14%
+80.32%
+39.14%
+126.71%
Source: Noonan, A., Lindong, I., & Jaitley, V. N. (2012). The Role of Historically Black Colleges and
Universities in Training the Health Care Workforce. American Journal of Public Health, Vol 103, No 3.
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While the total number of degrees conferred to African Americans rose in all professions, the
proportion of African Americans among total recipients of these degrees did not rise substantially.
For example, in medicine, African Americans made up 6.8% of all recipients of these degrees in
2000 and 6.9% in 2008. Similar results were found for nursing. Between the two time periods, the
percentage of nursing degrees among African Americans was stable at 9.6%.
Table 15. Percentage of African Americans Obtaining Degrees in
Health Professions, 2000 and 2008
Discipline
Medicine
Dentistry
Nursing
Pharmacy
Public Health
2000
13.7%
44.1%
11.2%
48.7%
17.4%
2008
14.6%
38.4%
9.1%
46.2%
8.2%
Percent Change
+.9%
-5.7%
-2.1%
-2.5%
-9.2%
Source: Noonan, A., Lindong, I., & Jaitley, V. N. (2012). The Role of Historically Black Colleges and
Universities in Training the Health Care Workforce. American Journal of Public Health, Vol 103, No 3.
HBCUs are particularly vulnerable during times of economic downturn due to serving students
who are frequently from poorer families, and highly dependent on financial aid: estimates
indicate that 90% of students enrolled in HBCUs receive financial assistance. These schools are
also more likely to have lower tuition rates than other non-minority serving institutions in order
to ensure adequate enrollment rates of low-income and diverse students. HBCUs further suffer
financially due to receiving smaller endowments than other institutions.151
Questions remain as to whether the increased funding from the ACA is sufficient to alleviate
concerns around HBCUs’ sustainability. Distributed among more than 100 universities and
colleges, the annual funding authorized through the law is relatively modest. Since HBCUs are
critical for the educational achievements of many African Americans from college through postgraduate studies, they are an important component of ensuring a diverse healthcare workforce.
Despite this promise, however, recent studies suggest that HBCUs are not playing a large enough
role in educating African American health professionals. As one study asked, “Why are the
enrollments of some critically needed health professionals increasing dramatically in traditionally
White institutions while they remain stable or are decreasing in HBCUs? Is there a need to
address the number of accredited programs in HBCUs?”152
In the fields of medicine and dentistry, whereas the need for diverse practitioners has been
recognized for decades, prospective students are able to only apply to three HBCU schools of
medicine and two of dentistry. While HBCUs saw a modest increase in the graduation of African
American practitioners between 2000 and 2008, this increase did not keep pace with growing
need, nor with graduation of African Americans from comparable programs at White institutions.
These patterns hold true for nursing and public health as well, and in some cases are even
worse.153
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Centers of Excellence
Legislative Context
Section 5401 of the ACA increases funding for the Centers of Excellence (COEs) and modifies the
funding allocation formula. The new methodology disburses funding to designated health
professions schools that serve underrepresented minorities. The program’s broad objective is to
diversify the health care workforce so that it reflects the current racial and ethnic makeup of the
population. The law authorizes $50 million in funding for COEs for FY 2010 through FY 2015 and
authorizes such sums as necessary for each following year.
Among the legislative requirements to be addressed by program applications are:
•
•
•
•
•
To create a competitive applicant pool through partnerships with institutions such as
community-based organizations in order to develop pipeline programs;
To develop or improve upon programs to augment the success of minority students;
To implement retention strategies for minority faculty members, infuse minority health
topics into resources, curricula, clinical opportunities and cultural competence objectives;
To focus research opportunities for students and faculty on health topics that are
applicable to underrepresented groups; and
To implement training programs for students to provide care to underrepresented
populations at community-based clinics.
Implementation Status and Progress
Grants have been awarded to COEs under the ACA for FY 2010 to FY 2013. Overall, each year, the
program has received less than half of the funding it was promised through the ACA, with funds
declining each year. According to HRSA’s website, in FY 2010, 12 COEs received a total of $25
million in funding; in FY 2011, 11 received a total of $24 million in funding, in FY 2012, 18 received a
total of $23 million in funding, and in FY 2013 17 entities received a total of $21 million in funding.
Table 16 shows the amount authorized for the COEs under the ACA and the actual amount
appropriated during this period.
Table 16. Authorized Funding in ACA and Actual Funding for
Centers of Excellence (COE), FY 2010-2014
FY 2010
COEs
FY 2011
FY 2012
FY 2013
FY 2014
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Requested
$50 m
$25 m
$50 m
$24 m
$50 m
$23 m
$50 m
$21 m
$50 m
$23 m
Note: Auth = Authorized
Emerging Programs and Models
The COE initiative explicitly focuses on enhancing opportunities for underrepresented minority
students and faculty. A review of funded program abstracts between FY 2010 – FY 2012 reveals that
they focus on the following racial and ethnic groups: 154
68
•
•
•
•
18 programs are explicitly focused on Hispanics or Latinos;
4 programs explicitly target African Americans;
5 programs target Native Americans; and
12 programs target minorities in general (i.e., more than one minority group).
A review of these programs revealed that several institutions are adopting common strategies and
practices to train and prepare a diverse health care workforce. For example, to recruit, train, and
retain students from racially and ethnically diverse heritage, many programs are increasing the
pool of qualified applicants through pipeline and outreach programs designed to inspire students
early on in their education to pursue health professions careers. Several programs are also offering
cultural competency training particularly through diverse clinical experiences in community
health settings as well as by increasing diversity among faculty members. For example, the
University of Pennsylvania has partnered with a public school in the area to implement pipeline
activities and also developed a research coalition with local community-based organizations. The
University of California, Los Angeles describes goals to increase the number of Hispanic medical
school faculty to promote more research related to minority health in the state. The University is
also partnering with community colleges to provide outreach to Hispanic students and assistance
in transferring them to four-year universities with the goal of increasing the number of students
qualified to apply to medical school.
Challenges and Next Steps
The COEs provide an important step in working to ensure that the health care workforce is both
reflective of a diverse population, and that healthcare professionals are well-equipped to serve
these populations from a variety of backgrounds. Leaders from the Coalition of Urban Serving
Universities report that pipeline programs are effective in reaching goals related to workforce
diversity, as half of the collaborative’s members reference achieving success in such programs.155
However, several barriers need to be overcome to meet such goals. COEs face challenges in
measurement and evaluation. For example, across COEs, plans for data collection and program
evaluation are inconsistent.156 A streamlined and cohesive effort to evaluate these initiatives will
facilitate decision-making and future policy in determining successful programs. For example,
California’s Office of Statewide Health Planning and Development (OSHPD) initiated efforts to
track and analyze educational and employment data by developing a website featuring
educational programs in the state.157
Moreover, barriers still exist in perceptions of the value and efficacy of cultural competency and
diversity programs. Objectives in cultural competence may be overlooked in curriculum
development and are instead something health professional schools view as additional, and
sometimes burdensome, requirements.158 Furthermore, many promising workforce diversity
programs, including COEs, have been declining in support. In 2006, these programs were harshly
cut, with support only gradually increasing over the years but not quite reaching the 2005
commitment.159 Perhaps due to this, academic institutions funnel a considerable amount of
funding into their pipeline programs. While almost all of the members of the Coalition of Urban
Serving Universities report relying on some amount of federal support for such programs, in the
majority of cases funding is primarily generated by the universities and health professions schools
themselves.160
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Health Care Professions Training for Diversity
Legislative Context
Section 5402 of the ACA reauthorizes two health care professions training programs for diversity.
First, the ACA amends the Public Health Service Act by reauthorizing Scholarships for
Disadvantaged Students (SDS) program and authorizing an increase in appropriations from $37
million to $51 million in FY 2010 and “such sums as necessary” for FY 2011 to FY 2014. Secondly, it
amends the Public Health Service Act by reauthorizing the Health Careers Opportunity Program
(HCOP) and allocating $60 million in funds for FY 2010 with such sums as necessary for FY 2011 to
FY 2014.
The SDS program offers scholarships for disadvantaged students who commit to working in
medically underserved areas. The goal of HCOP is to support individuals from disadvantaged
backgrounds in entering the health professions. Funds are intended to assist in:
•
•
•
•
•
•
•
Recruiting of disadvantaged students for health professions programs;
Assisting disadvantaged students’ entry into a health professions program;
Providing counseling and other services to ensure graduation from the school;
Providing preliminary education and training to disadvantaged individuals before they
enroll in a health professions school;
Publicizing financial aid opportunities for disadvantaged students;
Implementing training opportunities for primary care in non-profit community-based
settings; and
Enhancing partnerships with higher education institutions, schools and other communitybased organizations.
Section 5402 further reauthorizes and expands loan repayments for faculty of health professional
institutions.
Implementation Status and Progress
Under this provision, grants have been awarded for the SDS and HCOP programs through HRSA.
Both programs aim to enhance diversity among health professionals through their provision of
scholarships to financially and disadvantaged students. According to the HRSA website, in 2013
and in 2012 there were 99 active SDS grant programs, in 2011 there were 319 active programs, and
in 2010 there were 308 grant programs.
In 2012 there were 20 active HCOP grant programs, and in both 2011 and 2010 there were 33 active
programs, each year. HRSA’s website does not list any active HCOP programs for 2013. The
following table summarizes funding authorized by the ACA, and actual funding received for both
programs for FY 2010 to FY 2014.
70
Table 17. Authorized Funding in ACA and Actual Funding for Scholarships for
Disadvantaged Students and Health Careers Opportunities Program, FY 2010-2014
FY 2010
FY 2011
FY 2012
FY 2013
FY 2014
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Actual
Auth.
Requested
SDS
$51 m
$49 m
SSAN
$49 m
SSAN
$47 m
SSAN
$44 m
SSAN
$47 m
HCOP
$60 m
$22 m
SSAN
$22 m
SSAN
$15 m
SSAN
$14 m
SSAN
$0
Note: Auth = Authorized; SSAN = Such Sums as Necessary
Emerging Programs and Models
A review of funded programs reveals that all are geared toward disadvantaged students, and the
vast majority target students who are racially and ethnically diverse, or provide culturally and
linguistically competent care to diverse populations. The vast majority of programs describe goals
to ensure that health professions students from disadvantaged backgrounds are successful in preentry preparation, retention, graduation, and placement. Before enrollment into a health
professions program, many grantees are implementing activities for underrepresented minorities,
such as preparation in study skills and enhanced recruitment efforts. Retention strategies
described vary from job shadowing to academic support services, and financial support is
provided through scholarships earmarked for minority students. The following programs
highlight these actions:
•
The University of Alabama at Birmingham: The University is committed to bridging
health disparities and as such is focused on enhancing health professions diversity. Among
its efforts are: a program to enhance diversity in physician assistant program; summer
educational programs targeted to underrepresented minorities; and recruitment efforts
targeted in colleges with large minority populations.
•
Northern Arizona University: The Nursing Master’s program at the College of Health
and Human Services highlights its “commitment to recruiting and retaining educationally
disadvantaged students and those from diverse cultural and ethnic backgrounds to serve
underserved populations.”161 The grantee describes a specific focus on outreach and
retention of Native American students through its Native Journey to Academic Success
Program. The program has a previous history of graduating a significant number of
students who go on to practice in medically underserved areas (33% in 2010 to 2011) or
who practice in primary care (89 %).
•
Miami Dade College: The School of Nursing’s student body has historically been made
up of a majority of economically disadvantaged students, while enrollment includes a
large proportion of Hispanic and African American students. The program summary
describes that ”developing culturally competent registered nurses by establishing a system
that values the importance of culture in the delivery of health care services to all segments
of the population is a goal of the School of Nursing at MDC.”162 The school provides
expansive clinical experiences in its diverse region of Miami.
71
Challenges and Next Steps
Programs such as SDS and HCOP have proven successful in improving ratios of healthcare
practitioners in underserved areas, and graduating more minority providers, but they are not
without challenges that may inhibit their full potential. While financial support is critical for
achieving goals for recruitment, enrollment, and retention of a diverse student body, the majority
of funded programs identified do not describe in-depth objectives related to other retention
strategies that are also important for students’ success. Research shows that after enrollment,
diverse students benefit from tailored academic and psychosocial support in addition to financial
support.163 Promising workforce diversity programs, such as the HCOP and others have seen
waning financial support from the federal government over the years beginning in 2006. The ACA
showed significant promise in changing this trend by authorizing the highest level of funding
since 2005. However HCOP was funded for less than half of the authorized amount in 2010 and
2011.164
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IV. Renewed Opportunities and Remaining
Challenges for the Health Care Workforce
Among other equity objectives, the ACA is committed to supporting and expanding the nation’s
health care workforce, including enhancing efforts to ensure providers are more representative of
the populations they serve, are located in underserved areas, and possess skills to provide
culturally and linguistically competent care. The ACA reauthorizes and expands a number of
programs originally authorized under Titles VII and VIII of the Public Health Service Act, giving
preference to, in many cases, underrepresented minorities and services provided in traditionally
underserved, diverse communities. It also authorizes a series of novel workforce initiatives—such
as the National Health Care Workforce Commission, grants for community health workers, and
grants to test and support cultural competence education, among others—which offer the
potential for further strengthening the health care workforce. Despite this momentum, these
efforts may not be sufficient to match increases in demand expected from the growth in newly
insured populations following the operation of health insurance exchanges and state expansions
in Medicaid. Thus, while over 19 million racially and ethnically diverse enrollees may be eligible to
become newly insured through the exchanges and Medicaid, lack of funding may jeopardize, if
not prevent, programs from achieving their goals.
In this section, we discuss common themes and concerns which have emerged with the rollout of
the ACA’s health care workforce provisions. These were reiterated through our review of the
literature and emerging programs along with interviews with experts, providers, and community
representatives in the field. These concerns and challenges include:
•
•
•
Continued workforce shortages, especially in highly diverse areas;
Limited and declining funding for workforce diversity initiatives;
Reluctance to pursue diversity and cultural competency as a priority; and
Continued Workforce Shortages
Significant shortages are expected across the range of health professions—including doctors,
nurses, dentists, and others—potentially posing “one of the biggest threats” to the overall success
of health care reform.165 The implementation of the ACA is projected to increase the number of
insured by 30 million, over half of whom will be racially and ethnically diverse individuals. This
increase, along with an aging population and general population growth, will boost the demand
for medical services. In particular, steep increases in demand for primary care are expected, along
with an insufficient supply of providers to match this increase in many regions of the country. 166
Increase in demand, shortage of primary care providers. According to the Association of
American Medical Colleges, following the implementation of the ACA’s insurance expansions, and
by 2020, there will be an estimated shortage of 45,400 primary care physicians. This shortage
could have catastrophic effects on health, as it could significantly limit access to health care for
the very individuals and families the ACA intends to newly enfranchise. Recent estimates project
that states with fewest primary care providers per capita (those in the South and Mountain West)
are likely to have the largest increases in Medicaid enrollment, and accompanying health service
demand,167 and that the largest increases in demand are expected in Texas (with an estimated
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5.3% increase), Mississippi (4.8%), Nevada (4.5%), Idaho (4.4%) and Oklahoma (4.1%).168
Increases in demand, in turn, may be greater than average in regions with a large number of
currently uninsured or fewer primary care providers—i.e., places which are already stressed and
designated as health professional shortage areas or medically underserved areas.169 These areas,
in many cases, are also disproportionately comprised of low-income, racially, and ethnically
diverse individuals and families—thus, the potential impact could be greatest among this
population.
Geographic mal-distribution of providers. While the focus of recent research and programs
has been on increasing the sheer number of providers, perhaps even more critical is the
distribution of health care providers within and across states and localities.170 Physician
shortages—found to be already extensive—are expected to continue to be so as ACA
implementation rolls out, especially in rural and border regions, in low-income communities, and
regions with large proportions of minorities,171 elevating the importance of improving distribution
of providers in these areas through and beyond the opportunities put forth by the ACA.
Supply and diversity of specialty providers. The emphasis of the ACA, and recent reports
highlighting its impact on the health care workforce, has been on primary care. However, much
less attention has been given to specialty care despite an acute imbalance of specialists generally,
and by race and ethnicity172—a disparity that is only likely to grow as the number of insured
individuals expands. In a 2010 report on non-primary care specialty shortages, the Association of
American Medical Colleges’ Center for Workforce Studies predicted a 33% shortage in surgical
specialties, and “an undersupply of 33,100 surgeons and other specialists by 2015, increasing to
46,100 by 2020.”173 This shortage is likely to disproportionately affect low-income diverse
communities who already struggle to see private specialists, even with public insurance such as
Medicaid. 174
Limited and Declining Funding for Workforce Diversity Initiatives
Funding continues to be an overarching challenge for supporting the health care workforce,
generally, and particularly to advance diversity and cultural competency. Among the 19 provisions
reviewed in this report, the six explicitly focused on enhancing primary care capacity—such as
increasing the number of primary care physicians, physician assistants, and the National Health
Service Corps—have seen the greatest level of federal support and commitment. The other nearly
dozen provisions have either been severely under-funded or have not received any funding to
date.
National Healthcare Workforce Commission. Among provisions with no funding was a newly
introduced initiative known as the National Healthcare Workforce Commission, a 15-member
entity created to investigate the supply and demand of health care professionals. Despite its
establishment and appointment of members in 2010, the Commission received no funding. As one
member of the Commission stated, “it’s like ‘Waiting for Godot’…we are sitting on a park bench,
waiting for Godot. We’ll see if he shows up.”175 Critical questions that the Commission had sought
to address, particularly in advance of 2014, include: “How many doctors are needed? What is the
right mix of primary care physicians and specialists? Who will care for the millions of people
gaining Medicaid coverage? Should states require their laws to allow nurse practitioners and
physician assistants to do more of the work done by doctors?”176 Given that many of the law’s
more innovative actions to enhance the health care workforce have gone unfunded, several key
74
informants suggested that these efforts “have no teeth” and “have not done enough to move the
needle,” particularly from a diversity and health equity perspective.
Health professions pipeline programs. Among provisions that were underfunded were
important health professions pipeline programs, including the Centers of Excellence, Scholarships
for Disadvantaged Students, and the Health Careers Opportunity Program. While a body of
research suggests that such programs are critical for increasing minority entrants into the health
professions, federal funding for these programs has been waning over the years beginning in
2006.177 In 2006, funding for the Health Careers Opportunity Program was cut by 89% and for the
Centers of Excellence by 65%.178 Although the ACA showed significant hope and promise in
renewing support for these programs by authorizing the highest level of funding since 2005, many
of these programs were funded for less than half of the authorized amount in the early years of
ACA implementation.179 And with the advent of sequestration, funding for workforce initiatives—
particularly those addressing diversity and cultural competency—may not be fully realized in the
near term. As one key informant forecasted prior to the implementation of sequestration:
Currently-funded programs are already seriously underfunded. Sequestration will
only work to make a bad situation worse for programs currently funded and make
identifying funding streams for the unfunded discretionary health equity programs
nearly impossible outside the [Public Health and] Prevention Fund.
Mandatory and discretionary funding streams under the ACA are affected differently by
sequestration. According to a recent report, sequestration of mandatory appropriations for
workforce programs such as the National Health Service Corps is capped at 2%, while future
funding for discretionary programs is even more adversely affected. Likely outcomes as a result of
sequestration of discretionary funds suggest that:
With Congress now operating under enforceable discretionary spending caps
imposed by the [Budget Control Act], it may prove difficult to secure funding for
new programs and activities. To date, few new discretionary grant programs
authorized by ACA have received funding through the annual appropriations
process, though a handful of programs have received funding from the [Public
Health and Prevention Fund]. Even maintaining current funding levels for existing
programs with broad support and an established appropriations history can be a
180
challenge when there is pressure to reduce federal discretionary spending.
Minority-serving institutions. While HBCUs comprise only 3% of the nation’s higher education
institutions, they graduate nearly 3 in 10 African Americans with bachelor degrees, and a large
proportion of African American physicians, with the quality of those trained as measured by
performance of graduates with health professional degrees from HBCUs demonstrating no
difference compared with graduates from traditionally White institutions.181 Despite this evidence,
however, no national strategy or effort has been put forth to enhance the promising role of
HBCUs—or other minority-serving institutions—to support training future health professionals
from diverse racial and ethnic backgrounds.
Reluctance to Pursue Diversity and Cultural Competency as a Priority
Despite considerable progress in addressing health disparities, promoting a diverse and culturally
competent health care workforce largely remains a “tough sell”—politically, institutionally, and
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within the health care system. Reasons are varied and range from diversity and cultural
competency not being a priority to limited data and evidence linking such efforts to better
outcomes, and a narrow mindset on what diversity essentially means or encompasses.
Cultural competency is not a priority. Many of the unfunded provisions have an explicit focus
on enhancing cultural competency among health care providers. These provisions would support
creating an evidence base for cultural competence as well as coalescing standards and guidance
by authorizing the development, evaluation, and centralization of model cultural competence
curricula. However, in discussing cultural competency with key individuals in the field, it was
clear that this was not a priority. As one key informant noted, “…things that are not a priority,
like cultural competency, get put on at the very end…it’s not in the ‘urgent’ category.” In a survey
of the Coalition of Urban Serving Universities’ strategic plans, themes referencing or related to
diversity and cultural competence are frequently cited as core. However, accompanying pragmatic
goals for measurement, responsible parties or other specific actions are often absent.182
Other report interviewees cited similar resistance to cultural competency efforts, noting: “There
isn’t more uptake. There is someone at the institution that is aware that this exists. That’s not the
lever for change. What moves the institutions is reimbursement for quality of care. Schools don’t
survey cultural competency currently. They are not asking those questions. It’s buried in the
ACA.” Some suggested that the reason cultural competency efforts have not made it to the
forefront of priorities is that they are still trying to figure out how to implement broader
provisions around delivery and payment reform: “It’s evident that no one understands what is
happening broadly. There is no discussion of diversity and cultural competency because they’re
still struggling with what broader change means.” The problem many cited is that there simply is
insufficient federal support for the cultural competency agenda.
Limited health outcomes data on cultural competency. Despite some progress, meaningful
data and research linking cultural competency efforts to improved health outcomes are still
largely lacking, thereby encumbering efforts to elevate cultural competency as a health
intervention priority. A seminal study by Beach and colleagues in 2005 revealed that while there is
“excellent evidence” that cultural competence training improves the knowledge of health
professionals and “good evidence” that it impacts patient satisfaction, no studies link it to patient
adherence or health status outcomes.183 Generally, cultural competency training reviews have
focused on the effect of training on provider skills, knowledge, and attitudes, and the rigor of
methods for replication.184 Two recent studies assessing the impact of cultural competency
training on health care and mental health services found “limited evidence for effectiveness of
training on service delivery and health status.”185 And more recently, a 2010 randomized control
trial found that cultural competency training did not improve disparities in diabetes outcomes
between Black and White patients, raising further controversy over the true value of cultural
competency in reducing disparities.186 However, other research by Lieu and colleagues found that
cultural competence programs and policies in settings treating Medicaid children with asthma
reported higher quality of care.187
Overall, however, as Lie and colleagues concluded in their efforts to update cultural competence
research, there remains a paucity of high quality research” on this topic.188 Their study explicitly
underscores the importance of supporting explicit research on cultural competence curricula and
education as an intervention for improving health outcomes—much as the ACA had intended to
support under Section 5307, but has been unrealized to date.
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Limited political will or support for diversity and cultural competency. Efforts to advance
the diversity of the health care workforce may also be limited by perceptions regarding the value
of a diverse and culturally competent workforce. In fact, under each Presidential administration
in the past decade, diversity programs faced cuts in the federal budget, only to be reinstated by
Congress. 189 As has been recently argued by many thought leaders in the field, “a narrow,
historically civil rights-focused mindset about why workforce diversity is important persists, and
proponents of diversity programs often find themselves in a defensive posture.”190
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V. Moving Forward: Ensuring Diversity and Cultural
Competency in the Health Care Workforce
The ACA recognizes—in its goals and objectives—the formidable challenges around current and
future workforce shortages, the need for greater workforce diversity, and the importance of
promoting cultural and linguistic competence. As such, the ACA focuses considerable attention
on reinforcing and expanding the health care workforce to meet new demands in care—
particularly primary care—as nearly 30 million newly insured will enter the health care
marketplace by 2022. While a range of workforce related provisions were included in the law—
from reimbursement rates and incentives to building capacity within safety-net settings—this
report focuses mainly on those targeting the supply, diversity, and cultural competence of health
care professionals. A review of progress revealed that the majority of provisions which intended to
reauthorize well-established programs—such as the National Health Service Corps and other
Titles VII and VIII programs in the Public Health Service Act—were in fact implemented through
various grant programs, which in many cases gave preference for funding to institutions
addressing diversity, equity, and cultural competency.
Despite these efforts, many longstanding and promising initiatives were underfunded, and other
more novel programs remained unfunded, such as noted, the National Health Care Workforce
Commission and initiatives focused on cultural competency education and training of
underrepresented minorities. Our review also suggests that despite considerable progress in
expanding and enhancing diversity, the health care workforce is likely to continue to face
challenges to sufficiently address this priority, particularly to expand supply and capacity to serve
a large, and growing diverse patient population. As such, we identify at least six areas of priority
in working to ensure the nation’s workforce is adequate in supply and skill to serve a growing
insured, racially and ethnically diverse, and aging population. These priority areas build on
common themes we identified through a synthesis of research, policy review, grant opportunities,
grantee programs, and interviews around the implementation of the ACA, but also reflect
longstanding challenges, needs and roles. These priority areas include:
• Expanding of scope of practice;
• Encouraging interdisciplinary team-based care;
• Integrating the Enhanced CLAS Standards into workforce programs;
• Evaluating health care workforce diversity needs, capacity, and outcomes;
• Leveraging the ACA with philanthropic support; and
• Enhancing support for health professions schools and initiatives committed to diversity
and equity.
Expanding Scope of Practice
While the expansion of insurance coverage created through the ACA will open doors to care for
millions, great concern remains around the capacity of health care settings and systems to meet
the demand for services, especially for diverse, low-income, and other vulnerable populations. As
health professionals’ capacity is at the center of this concern, provider organizations and
policymakers are seeking ways to expand the pool of qualified practitioners. With the uncertainty
around support for many of the ACA’s workforce diversity provisions, expanding scope of practice
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may offer new opportunities for improving provider capacity and diversity and, in turn improving
access for historically underserved populations and geographic areas.
Scope of practice laws establish the legal framework by which medical services are delivered.
These laws encompass a full range of medical disciplines—from physicians and nurses to physical
therapists and dental hygienists—and govern which services each is allowed to provide and in
which settings.191 Generally, these laws are set by state governments, and thus vary from state to
state. “Some states allow individual professions broad latitude in the services they may provide,
while others employ strict limits. The nature of the limitations can either facilitate or hinder
patients’ ability to see a particular type of provider, which in turn influences health care costs,
access, and quality.”192
As the U.S. population continues to grow, diversify, and age, and as newly insured individuals
enter the health care market, many states and advocates are looking to Scope of Practice laws to
reassess the role that providers such as Advanced Practice Nurses (APNs) and Physician
Assistants (PAs) can play to fill shortages in primary care physicians. An Institute of Medicine
panel recommended that states consider expanding APNs’ scope of practice for primary care.193
Currently, 22 states and the District of Columbia have expanded the scope of practice for APNs,
who are permitted to practice independently, while in other states they require some level of
physician oversight.194 “Two-thirds of states with a shortage of primary care physicians also have
restrictive scope of practice laws, which may be a barrier to increasing access to primary care
services through APNs.”195
The Institute of Medicine’s 2010 report, The Future of Nursing: Leading Change, Advancing
Health,196 cited a large body of academic studies concluding that primary care provided by APNs
“has been as safe and effective as care provided by doctors.”197 Some studies also estimate that
APNs can provide up to 80% of the care that primary care physicians currently provide.198 Given
this experience and the comparable quality of care provided by APNs, coupled with the relatively
shorter time-frame required to train new entrants, expanding the supply of APNs is one potential
avenue for expanding primary care capacity across the country in a timely manner. This is also
especially important for expanding access to care among racially and ethnically diverse
communities, which are disproportionately more likely to be located in a health professional
shortage area or a medically underserved area. In fact, in certain parts of the country, APNs are
becoming more reflective of Non-White racial and ethnic patients than primary care physicians.
It is becoming more common to tap into the skills of these health care team members who are
often better reflective of local communities to close the communication or cultural gap between
physicians and patients. Many nurse practitioner training programs, in particular, are beginning
to make a concerted effort to increase racial and ethnic diversity among their students. For
example, more than half of the student body in the Women’s Health Care Nurse Practitioner
Program in Southern California is racially and ethnically diverse.199 Finally, the National
Committee for Quality Assurance’s 2011 medical home recognition standards permit APNs, and
also physician assistants, to lead medical homes where allowed by state law.”200 In certain
communities, particularly in rural areas, these medical homes or centers often represent the sole
provider of primary care.
Despite the promise of expanding scope of practice laws, many states are hesitant, and in some
cases, strongly opposed to do so, as reflected in this statement: “Organized physician groups,
which hold sway in most legislatures, are reluctant to cede professional turf to nurses. Arguing
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that nurse practitioners lack the necessary level of medical training, they insist that it is unsafe for
patients to be treated by nurse practitioners without a doctor’s supervision.”201
Encouraging Interdisciplinary Team-Based Care
Many of the ACA’s provisions are intended to promote patient-centered care, care coordination,
and recognition of health-related circumstances beyond the clinical encounter that may
significantly affect treatment adherence and outcomes. Culture and language-specific concerns,
community characteristics such as child care, safety, and access to healthy foods, all contribute to
the ability to deliver services efficiently and effectively. To integrate these and other priorities into
treatment plans, many health care providers are testing and implementing new models of care
delivery. One such model is the interdisciplinary team-based approach which involves health
professionals beyond physicians—including for example, nurses, social workers, mental health
professionals, and others—to coordinate care and other patient services. There are a range of
team-based approaches to care, and many of which are part of the Patient-Centered Medical
Home model of care. Commonly, health workers are part of a larger group that works under the
supervision of a physician to coordinate care, manage cases, and provide a comprehensive
approach to quality and safety. These arrangements have been associated with positive impacts
on quality of care and patient satisfaction, and are also being seen as an avenue to extend
availability of limited primary care providers.202
Community health workers, in particular, are seen as important players in team-based care. A
growing body of research documents that community health workers who are part of a team have
contributed to improved access to care, culturally competent chronic disease management, and
other care, as well as cost-effectiveness.203 For example, a Denver-based study found that
community health worker-led case management increased the use of primary and specialty care,
and reduced the use of urgent and inpatient care among patients.204 Another program in
Massachusetts—the Southeast Asian Birthing and Infancy Project—worked with trained,
bilingual, and bicultural community health workers to provide tailored prenatal care for culturally
and linguistically diverse patients, resulting in a significant increase in enrollment in early
prenatal care. And more recently, in Minnesota, the scope of practice of community health
workers was enhanced to include a greater role for them in medical care, including facilitating
patient-provider communication to clarify cultural practices, assisting with navigation of health
and human services, providing direct services to patients (including the provision of culturally
and linguistically appropriate health, wellness, disease prevention and management information),
assisting with chronic disease self-management and medication adherence, facilitating support
groups, and conducting health screenings, among other roles.205 Complementing this action is
Minnesota’s standardized competency-based training and credentialing program for community
health workers.
Team-based approaches which utilize social workers and nurse-practitioners, working alongside
primary care physicians have also shown promise particularly in the care of diverse and
vulnerable geriatric populations.206 Studies have linked this approach with improvements in
measures of general health, reduction in emergency department visits and hospital admissions,
along with greater physician and patient satisfaction. As hospitals, health centers, and other
settings seek to expand their capacity to provide primary care to vulnerable populations, more
widespread adoption of interdisciplinary team-based approaches to care—particularly involving
community health workers who offer a bridge to racially, ethnically, and linguistically diverse
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communities—may offer significant potential for improving access, quality, and outcomes. In a
recent interview, Ardis Dee Hoven, the president of the American Medical Association,
highlighted this point. She emphasized that shortages of certain health professionals place an
increased need to provide efficient services—primarily through team-based care— in order to
adequately serve the newly insured by the ACA.207
Integrating the Enhanced CLAS Standards into Workforce Programs
The release of the enhanced National Standards on Culturally and Linguistically Appropriate
Services (CLAS) in 2013 comes at a pivotal time in efforts to redress longstanding disparities and
advance health equity.208 Demographic changes across the country, greater recognition of gaps in
access to health services, and increased attention to the influence of race, culture, and language in
quality of care have elevated equity in both prominence and importance, leading to efforts that
span a spectrum of priorities from cultural competence training and use of interpreters to
organizational adaptation and transformation. This legacy of inequality as well as population
health and health care system change were among the driving forces that shaped the CLAS
blueprint. Building on the original standards issued in 2000, the scope of the new publication
expands its application to provide guidance for improving quality and safety, engaging
communities, meeting standards and accreditation requirements, and justifying the business case
through a set of identified actions around governance, leadership, and workforce; communication
and language assistance; and engagement, continuous improvement, and accountability.
The potential value of related guidance and application of the enhanced CLAS standards extends
in many directions and across a broad spectrum of the health care system. However, with the
enactment of the ACA, CLAS also comes at a critical “moment in time” with the potential to
greatly reduce the numbers of uninsured, transform the nation’s health care system, and improve
the lives of diverse and vulnerable populations around the country. In particular, the ACA has
made reducing disparities and improving equity a centerpiece of its vision and goals—
fundamental tenets that the enhanced CLAS standards share with the law.
CLAS standards are intended to serve as a set of guiding principles for health care organizations
in serving diverse populations and were developed to direct cultural and linguistic competency in
health care. Since their introduction in 2000, awareness of the CLAS standards has risen
consistently each year as the number of publications and citations continue to grow. The
standards aim to eliminate health disparities as culturally and linguistically appropriate care has
shown promise in helping to improve health care quality for diverse populations, particularly
through improved health knowledge, behavior, and patient satisfaction. The enhanced set of
standards was developed for several reasons including to ensure coordination and alignment with
the ACA. The standards are also now designed to be adopted as a set of 15 equally important
guidelines. According to the blueprint, organizations should integrate CLAS standards into their
practices and can raise awareness and achieve buy-in by promoting and emphasizing key points
around quality improvement, increased competition with other institutions and the avoidance of
possible malpractice and liability scenarios through improved culturally and linguistically
appropriate care.
CLAS standards align closely with the ACA’s provisions around workforce and systems capacity
including developing a culturally competent workforce, enhancing diversity, and integrating
equity priorities into leadership and governance (Table 18). Examples of the synergy between the
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ACA and CLAS standards include provisions around workforce support and diversity—e.g.,
tailoring CLAS Standards 1 and 4 to inform and guide primary care providers, nurses, dental and
mental health providers, pain care providers and community health workers on providing
culturally and linguistically appropriate care. Standard 3 addresses recruitment of a diverse
workforce, an essential goal to achieving health equity that is also underlined in the ACA.
Standard 13 describes community partnerships to enhance cultural and linguistic appropriateness
of care, a collaboration that many ACA grantees are pursuing in training and education programs.
Table 18. CLAS Standards with Direct Implications for
Workforce Diversity Provisions in the ACA
Standard
Description
1
Provide effective, equitable, understandable, and respectful quality care and
services that are responsive to diverse cultural health beliefs and practices,
preferred languages, health literacy, and other communication needs.
3
Recruit, promote, and support a culturally and linguistically diverse
governance, leadership, and workforce that are responsive to the population
in the service area.
4
Educate and train governance, leadership, and workforce in culturally and
linguistically appropriate policies and practices on an ongoing basis.
13
Partner with the community to design, implement, and evaluate policies,
practices, and services to ensure cultural and linguistic appropriateness.
Source: National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint
for Advancing and Sustaining CLAS Policy and Practice. (2013, April). HHS Office of Minority Health. Available at:
https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf
These standards offer clear opportunity to incorporate elements of culture and language into
workforce evaluation, impact, and assessment of ACA-funded programs. For example states
receiving State Health Care Workforce Development grants under the law can benefit from the
infusion and application of CLAS to ensure they effectively meet, reach, and incorporate the
nation’s diverse populations. Organizations and institutions can learn from previously developed
resources related to CLAS when embarking on the journey to implement culturally and
linguistically appropriate training, recruiting of diverse individuals, or when evaluating outcomes
related to workforce diversity programs. For example, the Massachusetts Department of Health
developed Making CLAS Happen: Six Areas for Action, a guide consisting of tools, case study
examples, and relevant resources to help a variety of entities get started with CLAS.209
Organizations and institutions can also look to states that have passed legislation requiring the
incorporation of culturally and linguistically appropriate standards of care for examples and “how
to’s” when implementing CLAS. Emerging outcomes from the CLAS-ACA alignment should be
monitored closely for opportunities to offer tools, models, experiences, expertise, and promote
the development of research; and potentially a clearinghouse of information on programs and
strategies that have successfully used CLAS to develop, undertake and integrate CLAS into their
business and service goals around the ACA.
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Evaluating Health Care Workforce Diversity Needs, Capacity, and Outcomes
With the numbers of insured projected to grow exponentially with the rollout of the ACA
marketplaces and state Medicaid expansions, understanding community, state, and national
workforce capacity needs—including creating a more diverse health care workforce—will be
especially critical for meeting new demands for services, for reaching historically underserved
populations, and ultimately, for eliminating disparities in access to and quality of care. To this
end, evaluating national, state and local strategies to improve workforce diversity across the
country as well as those within various disciplines offers the opportunity to determine progress in
advancing related goals around: meeting service needs and capacity; recruitment and retention of
a diverse workforce; and the effectiveness of cultural competency training and education.
Developing related designs, tools, and methodology will initially require key players in states and
localities to ensure that health care workforce diversity is part of any evaluation to assess health
professional shortages and needs. This may be especially important in communities experiencing
significant gaps in access to and quality of care. To this end, an evaluation of workforce diversity
needs and capacity may involve an understanding of:
• Racial and ethnic composition of health professionals in comparison to racial and ethnic
makeup of a geographic location—e.g., state, county, city , zip code, or census tract;
• Workforce shortages by health professions (including both specialty and primary care
providers), and by race and ethnicity;
• Federal, state, and local programs, including current funding or lack thereof, to address
workforce diversity;
• Challenges professionals may face in delivering care to a diverse patient population; and
• Barriers that diverse patients report in receiving care.
While a single entity could take responsibility for undertaking such an assessment—such as an
academic institution or a public health organization in a state, county, or city—this may be more
efficiently and effectively addressed through a collaboration or coalition of partners representing
public health, hospitals, health centers, philanthropy, and even partners outside the health care
sector. Such an evaluation may also be part of the Community Health Needs Assessment that
non-profit hospitals are required to undertake as authorized by the ACA, in collaboration with
the community they serve, to maintain their tax-exempt status.
Secondly, vested agencies and health care organizations should assess the effectiveness of existing
and new programs in recruiting and retaining underrepresented minorities. While many diversity
recruitment programs have emerged over the years for various health care professions, little is
known about which interventions work and why, along with outcomes they are associated with
most directly. As such hospitals, community health centers, academic institutions, and others
should consider collecting, analyzing, and reporting data on recruitment, retention, and
promotion opportunities by race and ethnicity. This analysis should occur in the context of
specific programs and funding streams that are most closely associated with increased diversity to
understand program scope, reach, and impact. For example, how effective are pipeline and
recruitment programs or innovative admissions policies in enlisting diverse individuals? How
long are racially and ethnically diverse students retained in such programs as compared to their
White counterparts? And are opportunities for growth and achievement comparable between
underrepresented minorities and others? What barriers or challenges remain for
underrepresented minorities?
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Thirdly, advancing evaluation of cultural competency education and training is critical to
understanding its impact on quality of care and outcomes and in expanding its acceptance more
broadly (Section 5307 in the ACA authorized such support but that provision has not received
funding to date). While modest research shows that cultural competency courses (ranging from
undergraduate level to medical residency can increase knowledge about common diseases among
ethnic populations and can increase cultural awareness, there is little evidence on its impact at
the clinical level.210 Rigorous comparative evaluations of cultural competency curricula is
important to understanding what works, why, and in what circumstances, and thus could shed
light on best practices and impact at the clinical level. Such evaluations should not be confined to
physicians—as has commonly been the case—but should extend to other health professions such
as nursing, dentistry, mental health, and allied health.
Finally, as part of the effort to evaluate process and outcome measures of workforce diversity,
health care providers, academic institutions, and others involved with training need to share their
research, best practices and lessons, particularly related to underrepresented minority student
outreach. Such actions can work to ensure that the individual and cumulative experiences in
assessing and addressing diversity become opportunities for others in developing their training
programs and can inform other strategies. In so doing this “collective wisdom” can assist in
strengthening the institutional climate for diversity across institutions.211
Enhancing Support for Health Professions Schools and Initiatives Committed to
Diversity and Equity
The enactment of the ACA, with the anticipated increase in racially and ethnically insured
individuals, and growing diversity in the U.S. population overall, elevate the importance of
training a diverse and culturally competent health care workforce. A trained, diverse
workforce can benefit health care settings, their patients, and communities in many
ways.212 It can work to assure that care recognizes and addresses language and cultural
distinctions that may affect processes and outcomes of care. It can add important
experience and perspective to executive, managerial, and other leadership positions, and
their related responsibilities.
Furthermore, research has demonstrated that racial and ethnic minority providers are
more likely to provide care in medically underserved areas than their White counterparts.
Studies also suggest that some patients who seek care from a practitioner of their own race
or ethnicity are more satisfied with their care, leading to improved understanding of
conditions, treatment adherence, and positive health behavior changes. Thus, while a
number of factors contribute to persistent health care disparities, “the lack of diversity
among health care professions has been shown to have a profound impact on minority
communities, leading to poor health outcomes or fragmented care at best.”213
Medical and health professions schools, minority-serving institutions, and health
professional societies stand to play an important and central role in attracting and training
a diverse health care workforce to meet growing need and demand expected in 2014.
Several institutions—such as the Association of American Medical Colleges (AAMC) and
urban universities— are beginning to take a leadership role in addressing this priority,
while others do not have the support that could reinforce their important role—such as
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HBCUs and other minority-serving institutions. In all, there is a need to garner more
widespread awareness and support for institutions committed to diversity and equity,
especially given federal funding through the ACA and otherwise for many efforts is
significantly compromised.
Urban universities across the nation that are anchored in local communities are wellpositioned to drive local innovations in health care workforce development and diversity
given their unique capacity, resources, and expertise. Urban universities produce nearly
half of the nation’s physicians and dentists, and 40% of nurses and public health
professionals.214 These universities are often seen as a “gateway” to higher education for
urban students—many of whom are from diverse, underserved, and high-need
communities—particularly in transitioning to health professions programs, and thus
represent a tangible opportunity for integrating diversity priorities. A range of actions at
the university-level are important for advancing diversity and equity, including, for
example: a commitment from university leadership to advancing this priority; partnerships
with education institutions to establish or strengthen pipeline programs from primary and
secondary to graduate school level; and partnerships with community health care settings
and safety-net providers to offer community-based health professions training. 215
A promising initiative, known as Urban Universities for HEALTH (Health Equity through
Alignment, Leadership, and Transformation of the Health Workforce) is being led by
AAMC in partnership with the Coalition of Urban Serving Universities and the Association
of Public and Land-grant Universities, with support from the National Institutes of
Health.216 The goal of this effort is to enhance and expand a culturally sensitive, diverse,
and prepared health workforce that can improve health and reduce disparities in urban
communities. An initial cohort of five urban institutions (a “learning collaborative”) is
working to develop metrics, assess institutional capacity, and test and share innovative
approaches to talent development with the aim of improving the health of urban
underserved populations. This effort represents a unique opportunity to test, strengthen,
and enhance diversity and cultural competency programs at the university level, and could
also be a resource for promoting ACA’s workforce programs and policies.
Minority-serving institutions have great potential to train a more diverse health care
workforce, particularly as these institutions train a large percentage of minority health
professionals and evidence demonstrates that the academic performance of graduates from
minority-serving institutions is not different from graduates of traditional universities. In
fact, a review of academic and professional performance of students from HBCUs and
traditional universities found that minorities from HBCUs are just as likely to graduate,
pass licensing exams, and enter practice as nonminorities from traditional universities.217
However, over the years, there has been little growth in degrees conferred by HBCUs for
the health professions. As a recent American Journal of Public Health article questioned:
“[If] the mission of HBCUs is to serve a major provider of education for African
Americans…[w]hy are they not playing a larger role in the education of African American
health professionals as we seek health equity?” 218 A focused national strategy is critically
needed to enhance and support the role of HBCUs and other minority-serving institutions
to train diverse health professionals, given these institutions already educate and train a
cadre of professionals from diverse heritage.
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Another avenue for attracting diverse students in the health professions is through
recruitment and mentorship programs in community colleges. For example, The Robert
Wood Johnson Foundation Clinical Scholars program partners with California’s community
colleges—comprised of a large proportion of diverse students—to mentor, advise, and offer
resources to students to help them transfer to a health professions career pathway and
enter medical schools or other universities with health professions programs. These efforts
draw on talent that may exist in many underserved communities that are often overlooked.
In all, these initiatives and resources are examples of strategies for assuring that the
workforce related goals of the ACA are not lost among the efforts to reduce support,
sequestration, or similar broader federal actions. As they reflect many of the provision
objectives seen as critical to meeting the needs of newly insured, their success would
contribute significantly to assuring more effective individual and community-based as well
as informed access to and quality of care.
Leveraging Resources Provided through the ACA with Philanthropic Support
Given the many financial and ideological challenges to advancing health equity across states and
communities, advancing workforce diversity and cultural competency will require supplemental
support from other funding avenues—both federally and through the private sector. Well-funded
programs, particularly those with mandatory funding in the ACA, may offer some opportunity.
For example, the Patient-Centered Outcomes Research Institute authorized through 2019, may
offer an avenue to test efficacy of cultural competency or other workforce diversity initiatives.
The private sector may also fill gaps in support. In fact, in many communities, national, state, and
local philanthropies and foundations are beginning to fill an important void to support the health
care workforce, particularly where sufficient support from the ACA and other federal sources has
not occurred. Such assistance has included scholarships and loan repayments, mentorship
programs, health care workforce capacity assessments, training programs, investments in
community health workers, and improving provider capacity.219
In addition to providing direct support to health care workers, philanthropic organizations can
leverage resources to advance important and broader workforce initiatives under the ACA that
may not be realized due to limited or no appropriations, or other actions. In the absence of
appropriations, there is a need for stronger actions to encourage the federal government to allow,
if not work with, private foundations and philanthropies to address many of the ACA’s unfunded
provisions. These may include, for example, the National Health Care Workforce Commission—
for which foundation or other non-federal support is currently prohibited220—as well as others
such as support for model cultural competency curricula development and evaluation, and
enhancing the community health workforce. As part of this effort, advocacy and other health
provider organizations may need to frame the diversity and cultural competence discussions
within the broader context of “quality” to ensure continued support at the federal, state, local and
philanthropic levels. One key informant particularly highlighted this priority:
We know that the presence of health disparities means a lack of quality in the system. My
goal is to tie it all together. By 2014 when we have the newly enfranchised, I hope we
recognize how inter-dependent this work is—readmissions [as well as] the educational
piece as far as who we choose to engage, such as students with the greatest capacity.
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VI. Conclusion
The ACA’s numerous provisions reaffirm many existing workforce efforts and intend to advance
new initiatives—although not funded or underfunded in some cases—such as creating a national
workforce commission, promoting cultural competence education, and supporting
underrepresented minorities in health professions. At its core, this emphasis seems
to acknowledge the formidable challenges that lie ahead in redressing limitations and disparities
of the past affecting access to timely, high quality health care, and assuring that the intent of the
new law to truly enfranchise new populations is fulfilled. The related demand for a high quality,
diverse workforce will only grow, but will require significant resources and political will. What
remains much less clear in moving into the fifth year of ACA implementation is whether the
resources and political will to support a broad spectrum of critical programs and actions will be
sufficient to meet service goals and people’s needs.
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Appendix A. Key Informants & Contributors
The Texas Health Institute would like to acknowledge and thank the many individuals who
contributed valuable information, feedback, and perspective on various topics covered under the
Affordable Care Act & Racial and Ethnic Health Equity Series. Nearly 70 individuals were
interviewed or consulted. They represented a range of sectors—from federal, state, and local
agencies to hospitals, health centers, health plans, professional associations, health policy experts,
advocates, and community-based representatives. Note: Opinions expressed in this report are of
the authors only and are not to be attributed to the individuals or organizations listed below unless
noted as such in the report.
Jennifer Babcock, MPH
Vice President for Exchange Policy and
Director of Strategic Operations
Association for Community Affiliated Plans
Elise Chayet
Associate Administrator
Clinical Support Services and Planning
Harborview Medical Center
Ignatius Bau, JD
Health Policy Consultant
California
Anthony L-T Chen, MD, MPH
Director of Health
Tacoma-Pierce County Health Department
Sonciray Bonnell, MALS
Tribal Community Program Analyst
Cover Oregon
Kathy Ko Chin, MS
President and CEO
Asian & Pacific Islander American Health
Forum
Tangerine M. Brigham
Deputy Director of Health
Director of Healthy San Francisco
San Francisco Department of Public Health
Pamela Clifford
Director, Health Care Innovation
Hennepin County Medical Center
Alex Briscoe
Director, Alameda County Health
Care Services Agency
Kathryn L. Coltin, MPH
Director, External Quality Data Initiatives
Harvard Pilgrim
Rita Carreón
Deputy Director
Clinical Strategies & Health Care Equity
America’s Health Insurance Plans (AHIP)
Onofre Contreras, Jr.
External Affairs Staff
Cover Oregon
Adela Flores-Brennan, JD, MA
Navigator Manager
Colorado Health Benefit Exchange
Susan Chapman, Ph.D.
Director of the Allied Workforce Program
UCSF Center for the Health Professions
Alice A. Coombs, MD
American Medical Association’s
Commission to Eliminate Healthcare
Disparities
U. Michael Currie, MPH, MBA
Director, Health Equity Services
Enterprise Clinical Services
UnitedHealth Group
88
Benjamin Danielson, MD
Board Member, Washington State
Exchange
Medical Director, Odessa Brown Children’s
Clinic
Dan Hawkins
Senior Vice President
Public Policy and Research Division
National Association of Community Health
Centers
Daniel Dawes
Executive Director, Government Relations,
Policy, & External Affairs
Morehouse School of Medicine
Joan Henneberry, MS
Principal, Health Management Associates
(Formerly Planning Director, Colorado
Health Insurance Exchange)
Frank DiBiase
Assistant Division Director
Environmental Health
Tacoma-Pierce County Health Department
Laura Hitchcock, JD
Policy Research & Development Specialist
Public Health — Seattle & King County
Heather Hodge, M.Ed
Manager, Chronic Disease Prevention
Programs
YMCA of the USA
Catherine Dower, JD
Associate Director
UCSF Center for the Health Professions
Carlissia Hussein, RN, DrPH
Director, Office of Minority Health and
Health Disparities
State of Maryland
Tamarah Duperval-Brownlee, MD, MPH,
FAAFP
Chief Medical Officer and Chief Executive
for Clinical Services
Lone Star Circle of Care
Rhonda M. Johnson, MD, MPH
Medical Director, Health Equity & Quality
Services
Highmark Inc.
Bethany Fray
Senior Communications Specialist,
Washington State Exchange
NaiKasick, Director
Health Promotion and Cultural and
Linguistics Services
L.A. Care
Anne Gauthier, MS
Senior Program Director
National Academy for State Health Policy
Sue Grinnell, MPH
Director, Office of Healthy Communities
Washington State Department of Health
Myung Oak Kim
Director of Communications and Outreach
Colorado Health Benefit Exchange
Carrie Hanlon, MA
Program Manager
National Academy for State Health Policy
Casey Korba, MS,
Director, Prevention and Population
Health
America’s Health Insurance Plans
Romana Hasnain-Wynia, PhD, MS
Scientific Program Leader, Health
Disparities
Patient-Centered Outcomes Research
Institute
Barbara Lardy, MPH
Senior Vice President
Clinical Affairs and Strategic Partnerships
America’s Health Insurance Plans
89
Michelle Proser
Director of Research
Public Policy and Research Division
National Association of Community Health
Centers
Matt M. Longjohn, MD, MPH
Senior Director of Chronic Disease
Prevention Programs
YMCA of the USA
David Mann, MD, PhD
Epidemiologist, Office of Minority Health
and Health Disparities
State of Maryland
Wayne Rawlins, MD, MBA
National Medical Director, Racial and
Ethnic Equality Initiative
Aetna
Katie Marcellus
Director, Program Policy
California Health Benefit Exchange
Thomas C Ricketts, PhD, MPH
Cecil G. Sheps Center for Health Services
Research
The University of North Carolina at Chapel
Hill
Lori Mitchell
Chief Financial Officer
UW Medicine Health System
Marguerite J. Ro, DrPH
Chief, Assessment, Policy Development
and Evaluation Section
Public Health - Seattle and King County
Teresa Niño
Director
Office of Public Engagement (OPE)
Centers for Medicare & Medicaid Services
U.S. Department of Health & Human
Services
Shannon Sale, MHA
Vice President
Planning and Business Development
Grady Health System
Marc Nivet, Ed.D.
Chief Diversity Officer
Association of American Medical Colleges
Cary Sanders, MPP
Director of Policy Analysis and the
Having Our Say Coalition
California Pan-Ethnic Health Network
Rachel Oh, JD
Community Affairs Manager
Cover Oregon
Lisa Sbrana, JD
Counsel to the Exchange, New York Health
Benefit Exchange
John Oswald, PhD, MPH
Asst. Vice President, Research
National Association of Public Hospitals &
Health Systems
Katherine Schlaefer, MPH
Senior Program Manager
Health Equity Services Program
UnitedHealth Group
Peggy Payne, MA
Director, Multicultural Communications
Cigna
Samantha Shepherd, MA
Program Specialist
Cover Oregon
Patrick Pine
Chief Administrative Officer
Robert F. Kennedy Medical Plan-California
Chad M. Silva, JD
Policy Director
Latino Coalition for a Healthy California
Susan Pisano
Vice President of Communications
America’s Health Insurance Plans
90
Donald Weaver, MD
Chief Medical Officer, Clinical Affairs
National Association of Community Health
Centers
Natalie Slaughter, MSPPM
Senior Health Research Associate
America’s Health Insurance Plans (AHIP)
Johnese Spisso
Chief Health System Officer & Vice
President
UW Medicine Health System
Danielle S. Williams, JD
Consumer Outreach and Engagement
Manager
Connecticut Health Insurance Exchange
Christina Stasiuk, DO
National Medical Director of Health
Disparities
Cigna
Mara Youdelman, JD, LLM
Managing Attorney
National Health Law Program
Tequila Terry, MBA
Director, Plan and Partner Management,
Maryland Health Benefit Exchange
Paul Tibbits, Jr.,
Consumer Support Group
Center for Consumer Information and
Insurance Oversight
U.S. Department of Health and Human
Services
Michele Toscano, MS
Head, Business Mgmt, Planning and
Reporting
Program Manager
Racial & Ethnic Equality Initiative
Aetna
Nigel Turner, MPH
Division Director, Communicable Disease
Control
Tacoma-Pierce County Health
Department, Washington
David Vance
Division Director
Strengthening Families Division
Tacoma-Pierce County Health Department
Mike Vanderlinde
Director, Government Financial Relations
& Reimbursement
Harborview Medical Center
91
Appendix B. ACA Workforce Diversity Progress At-A-Glance
Provision
Summary
Funding Authorized
by the ACA
Estimated
Funding Received
Summary of
Implementation Progress
Increasing the Supply and Diversity of Healthcare Professionals
Health care
workforce loan
repayment programs
§ 5203
Training in family
medicine, general
internal medicine,
general pediatrics,
and physician
assistantship
§ 5301
Establishes a pediatric specialty loan
repayment program for
professionals working in pediatric
medical and surgical specialties or
child mental healthcare. Priority is
given to applicants that, among
other criteria, have familiarity with
cultural and linguistic competence.
Pediatric specialists:
FY 2010: $30 m
FY 2011: $30 m
FY 2012: $30 m
FY 2013: $30 m
FY 2014: $30 m
Establishes a grant program to
support primary care training.
Funds are to be used for program
operation and development,
financial assistance, and capacity
building. Among other criteria,
priority is given to entities with a
record of training individuals from
underrepresented minority groups
and familiarity in providing cultural
competency training.
Training programs:
FY 2010: $125 m
FY 2011-2014: SSAN
$0
This provision has received no funding as of
this writing.
FY 2010: $39 m in
annual discretionary
appropriation + $198
m from the
Prevention & Public
Health Fund.
FY 2011: $39 m
FY 2012: $39 m
FY 2013: $37 m
September 2010: HRSA awarded 82
primary care residency training programs
and 28 physician assistant training
programs.
Child Mental Health
professionals:
FY 2010: $20 m
FY 2011: $20 m
FY 2012: $20 m
FY 2013: $20 m
FY 2014: $20 m
Capacity building grants:
FY 2010: $750,000
FY 2011: $750,000
FY 2012: $750,000
FY 2013: $750,000
FY 2014: $750,000
By 2015, these programs are expected to
train 889 new primary care physicians and
700 physician assistants.
Provision
Summary
Funding Authorized
by the ACA
Estimated
Funding Received
Summary of
Implementation Progress
Training
opportunities for
direct care workers
§ 5302
Awards grants to eligible entities
that provide training opportunities
for direct care workers employed in
long-term care settings.
FY 2010 – 2013: $10 m
$0
This provision has received no funding as of
this writing.
Training in general,
pediatric, and public
health dentistry
§ 5303
Awards 5-year grants to fund dental
training activities (faculty
development, financial assistance,
pre and post doctoral training in
dental primary care) with an
emphasis on programs that train
students from disadvantaged
backgrounds or whose programs
focus on care for the underserved.
FY 2010: $30 m
FY 2011 – 2015: SSAN
FY 2010: $15 m
FY 2011: $17 m
FY 2012: $20 m
FY 2013: $19 m
Grants have been awarded for Predoctoral
Training in General, Pediatric, and Public
Health Dentistry and Dental Hygiene for
FYs 2010 – 2013. All grantees report some
kind of priority for targeting diverse dental
students, focusing on cultural competency
training, or serving a diverse dental patient
population.
Mental and
behavioral health
education and
training grants
§ 5306
Establishes grants programs for
academic institutions to recruit and
educate students in mental and
behavioral health disciplines.
Priority is given to institutions that
have high participation of
individuals from diverse
backgrounds.
FY 2010-2013: $35 m
-$8 m (social work);
-$12 m (psychology);
- $10 m (professional
child mental
health);
-$5 m (paraprofessional
child mental health)
FY 2010: $0 m
FY 2011: $0 m
FY 2012: $10 m
FY 2013: $0 m
September 2012: HRSA awarded $10 m to
24 graduate social work and psychology
academic institutions. All funded programs
target high-needs and medically
underserved communities. Ten explicitly
report that their programs address racial
and ethnic diversity.
Nurse education,
practice, and
retention grants
§ 5309
Establishes grants to expand the
nursing workforce by training,
retaining and enhancing patient
care provided.
FY 2010 – 2014: SSAN
FY 2011: $40 m
FY 2012: $40 m
FY 2013: $37 m
July 2011: HRSA awarded Nurse Education,
Practice, Quality and Retention Grants to
33 entities. In 2012 there were 24 active
grants and in 2013 there were 37 active
grants.
93
Provision
Summary
Funding Authorized
by the ACA
Estimated
Funding Received
Summary of
Implementation Progress
Workforce diversity
grants
§ 5404
Amends Title VIII, Section 821 of the
Public Health Service Act, modifying
the original Nursing Workforce
Diversity Program to include
advanced education preparation,
stipends for diploma or associate
degree nurses to enter a bridge or
degree completion program, and
student scholarships or stipends for
accelerated nursing programs.
No funding specifications
provided
FY 2011: $3.6 m
July 2011: HRSA awarded Nursing
Workforce Diversity Grants to 11 entities.
As described in the Funding Opportunity
Announcement, eligible entities are
required to have some kind of commitment
and activities related to advancing diversity
and cultural competency. In 2011 there
were 26 active grants. In 2012 there were
40 active grants and in 2013 there were 41
active grants.
Grants to promote
the community
health workforce
§ 5313
Authorizes grants under the CDC to
train and supervise community
health workers to care for medically
underserved communities.
FY 2010 – 2014: SSAN
$0
While not funded, community health
workers have been funded through other
sections of the ACA, such as the
Community Transformation Grants.
FY 2010: $320 m
FY 2011: $414 m
FY 2012: $535 m
FY 2013: $691 m
FY 2014: $893 m
FY 2015: $1.155 b
*subsequent amounts
based on previous year’s
funding
FY 2010: $142 m
FY 2011: $315 m
FY 2012: $295 m
FY 2013: $285 m
October 2011: HHS announced funding for
5,418 loan repayment programs and $46 m
in funding to scholarship programs.
February 2012: HHS announced a pilot
program “Student to Service”.
October 2012: HHS announced $229.4 m in
funding for 4,600 awards in scholarships
and loan repayment.
February 2013: HHS announced more than
$10 m in funding for loan repayment to 87
medical students specializing in primary
care.
Workforce Support for the Health Care Safety Net
Funding for National
Health Service Corps
§ 5207
Provides scholarships and student
loan repayments for primary care
students and clinicians who commit
to providing care in federally
designated Health Professional
Shortage Areas.
94
Provision
Interdisciplinary,
community-based
linkages
§ 5403
Summary
Authorizes grants to plan, develop
or operate Area Health Education
Centers or to maintain and improve
existing Centers that recruit and
train disadvantaged students into
health professions to work in
underserved areas.
Funding Authorized
by the ACA
FY 2010: $125 m
FY 2011: $125 m
FY 2012: $125 m
FY 2013: $125 m
FY 2014: $125 m
Estimated
Funding Received
FY 2010: $33 m
FY 2011: $33 m
FY 2012: $27 m
FY 2013: $28 m
Summary of
Implementation Progress
Grants have been awarded for Area Health
Education Centers as follows:
FY 2010: 11 infrastructure awardees;
43 point of service awardees.
FY 2011: 11 infrastructure awardees;
49 point of service awardees.
FY 2012: 11 infrastructure awardees;
48 point of service awardees.
FY 2013: No active grants are listed on
HRSA website.
All grantees target underserved and
disadvantaged populations, and at least
half explicitly cite targeting diverse
populations in their grant descriptions.
Distribution of
additional residency
positions
§ 5503
Directs the Secretary of HHS,
beginning July 1, 2011, to convert
unfilled hospital residency positions
under the Graduate Medical
Education (GME) program to slots
for primary care physicians
N/A
N/A
November 2010: CMS issued final
regulations regarding the redistribution of
resident cap slots from hospitals that were
below their caps to hospitals that applied to
CMS for increased slots to expand their
residency programs.
August 15, 2011: CMS announced teaching
hospitals to receive changes to their
resident caps. Excess slots from 267
hospitals were re-directed to 58 hospitals.
Of these, 24 are located in cities where over
50% of the residents are Non-White.
95
Provision
Summary
Funding Authorized
by the ACA
Estimated
Funding Received
Summary of
Implementation Progress
Cultural Competency Education and Training
Advancing research
and treatment for
pain care
management
§ 4305
Requires the IOM to hold a
Conference on Pain to develop the
research agenda for pain as a public
health problem. A report must be
submitted to Congress. Authorizes
HRSA to establish a new grants
program for health professions
schools to develop and implement
programs for training health care
professionals in the diagnosis,
treatment, or management of pain.
FY 2010 – 2011: SSAN
$0
The IOM Conference on Pain occurred as 5
meetings between November 22, 2010 and
April 19, 2011.
On June 29, 2011 the committee publicly
released the resulting report titled Relieving
Pain in America: A Blueprint for
Transforming Prevention, Care, Education,
and Research. The report highlights several
aspects of racial and ethnic disparities in
pain care.
HRSA grants have not been implemented.
Cultural competency,
prevention, and
public health and
individuals with
disabilities training
§ 5307
Authorizes grants for research,
demonstration projects and model
curricula in cultural competency
FY 2010 – 2015: SSAN
$0
This provision has received no funding as of
this writing.
Demonstration
projects to address
health professions
workforce needs
§ 5507
Authorizes grants for new
demonstration projects to develop
core training competencies,
including cultural and linguistic
competence, and certification
programs for personal or home care
aides.
FY 2010: $5 m
FY 2011: $5 m
FY 2012: $5 m
FY 2010: $4.2 m
FY 2011: $4.4 m
FY 2012: $4.4 m
In September 2010, HRSA awarded grants
to six states (Massachusetts, California,
Iowa, Michigan, North Carolina, and Maine)
under the Personal and Home Care Aide
State Training (PHCAST) Grant Program.
The PHCAST Report to Congress on Initial
Implementation has been released.
96
Provision
Summary
Funding Authorized
by the ACA
Estimated
Funding Received
Summary of
Implementation Progress
FY 2008-2019: $255 in
mandatory funding.
$100 m for Hispanic
Serving Institutions
$85 m for Historically
Black Colleges and
Universities
$15 million for
Predominantly Black
Institutions
$30 million to Tribal
Colleges and Universities
$15 million to
Alaska/Hawaiian Native
Institutions
$5 million to Asian
American and Pacific
Islander Institutions
$5 million to Native
American non-tribal
serving institutions.
FY 2010: $50 m
FY 2011: $50 m
FY 2012: $50 m
FY 2013: $50 m
FY 2014: $50 m
FY 2015: $50 m
The federal
government began
providing mandatory
funding through the
ACA to the HBCUs
and other minority
colleges as of 2010.
While HBCUs saw a modest increase in the
graduation of African American
practitioners between 2000 and 2008, this
increase did not keep pace with growing
need, nor with graduation of African
Americans from comparable programs at
White institutions.
FY 2010: $25 m
FY 2011: $24 m
FY 2012: $23 m
FY 2013: $21 m
Grants were awarded to Centers of
Excellence as follows: 12 entities funded in
FY 2010; 11 entities funded in FY 2011;
18 entities funded in FY 2012; and 17
entities funded in FY 2013. A review of
grantees between FYs 2010–2012 reveals
that 18 explicitly target Hispanics or
Latinos; 4 target African Americans; 5
target Native Americans; and 12 target
minorities in general.
Health Care Workforce Investment in Academic Settings
Investment in
historically black
colleges and
universities and
minority-serving
institutions.
§ 2103
The accompanying Health
Education and Reconciliation Bill
amends the Higher Education Act by
lengthening the authority to award
funding to HBCUs and other
minority-serving institutions
through 2019
Centers of excellence
§ 5401
Provides funding for Centers of
Excellence which support programs
to recruit, train and retain diverse
health professions students.
97
Provision
Health care
professionals training
for diversity
§ 5402
Summary
Authorizes appropriations to
support scholarships and
educational assistance for
disadvantaged students.
Funding Authorized
by the ACA
Estimated
Funding Received
Scholarships for
Disadvantaged Students
(SDS):
FY 2010: $51 m
FY 2011-2014: SSAN
SDS:
FY 2010: $49 m
FY 2011: $49 m
FY 2012: $47 m
FY 2013: $44 m
Health Careers Opportunity
Program (HCOP):
FY 2010: $60 m
FY 2011-FY 2014: SSAN
HCOP:
FY 2010: $22 m
FY 2011: $22 m
FY 2012: $15 m
FY 2013: $14 m
Summary of
Implementation Progress
Grants were awarded for SDS and HCOP in
FYs 2010 to 2013 as follows:
FY 2010: 33 HCOP awardees
308 SDS awardees
FY 2011: 33 HCOP awardees
319 SDS awardees
FY 2012: 20 HCOP awardees
99 SDS awardees
FY 2013: no HCOP awardees listed
99 SDS awardees
All grantees describe goals for medically
underserved populations and
disadvantaged students, and the vast
majority target students who are racially
and ethnically diverse.
Health Workforce Evaluation and Assessment
National healthcare
workforce
commission
§ 5101
Creates a workforce commission to
evaluate, recommend, and meet the
demand for health care workers
through research and data
collection.
SSAN (No years specified)
$0
State Health Care
Workforce
Development Grants
§ 5102
Authorizes planning and
implementation grants to state
workforce investment boards to
plan workforce development
activities.
Planning grants:
FY 2010: $8 m
Subsequent FYs: SSAN
FY 2010: $6 m
Implementation grants:
FY 2010: $150 m
Subsequent FYs: SSAN
*Note: SSAN = Such Sums as Necessary
98
September 2010: Comptroller General of
the Government Accounting Office
announced Commission nominations for
15-member body. The Commission has
been unable to conduct business due to
lack of funding.
September 2010: HHS announced 25 states
received 1-year planning grants and 1 state
received a 2-year implementation grant.
Endnotes
1
Agency for Healthcare Research and Quality. National Healthcare Disparities Report 2011, March 2012.
Available at: www.ahrq.gov/qual/qrdr11.htm. Last accessed: February 22, 2013.
2
Ibid.
3
Smedley, B. D., Butler, A. S., & Bristow, L. R. (2004).In the nation's compelling interest: Ensuring
diversity in the health-care workforce. National Academy Press.
4
Smedley, B. D., & Stith, A. Y. (2003).Unequal treatment: Confronting racial and ethnic disparities in
health care (Vol. 1). National Academy Press.
5
Goodwin J., Matyas D., & Selvam, D. (2012, October) Promoting Greater Diversity in the Healthcare
Workforce. AHLA Connections, 32 – 36.
6
Castillo-Page, L. (2010). Diversity in the Physician Workforce: Facts & Figures 2010. Association of
American Medical Colleges, Diversity Policy and Programs. Available at:
https://members.aamc.org/eweb/upload/Diversity%20in%20the%20Physician%20Workforce%20Facts%
20and%20Figures%202010.pdf. Last accessed: February 24, 2013.
7
U. S. Department of Health and Human Services, Health Resources and Services Administration. (2010,
March). The registered nurse population: Findings from the 2008 national sample survey of Registered
Nurses. Available at: http://bhpr.hrsa.gov/healthworkforce/rnsurvey/2008/. Last accessed: February 24,
2013.
8
Castillo-Page, L. (2010). Diversity in the Physician Workforce: Facts & Figures 2010. Association of
American Medical Colleges, Diversity Policy and Programs. Available at:
https://members.aamc.org/eweb/upload/Diversity%20in%20the%20Physician%20Workforce%20Facts%
20and%20Figures%202010.pdf. Last accessed: February 24, 2013.
9
Ibid.
10
U.S. Department of Health and Human Services (2011, April).HHS Action Plan to Reduce Racial and
Ethnic Disparities: A Nation Free of Disparities in Health and Health Care. Available at:
http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf. Last accessed: February 3,
2013.
11
Sullivan Commission on Diversity in the Healthcare Workforce. (2004). Missing persons: Minorities in
the health professions: A report of the Sullivan Commission on diversity in the healthcare workforce.
12
Ibid.
13
Gardner, J. (2005). Barriers influencing the success of racial and ethnic minority students in nursing
programs. Journal of Transcultural Nursing, 16(2), 155-162.
14
Dunivin, D. L. (1994). Health professions education: The shaping of a discipline through federal
funding. American Psychologist, 49(10), 868.
15
U.S. Department of Health and Human Services.(1997, April). Testimony on Health Professions &
Nursing Education Programs by Claude Earl Fox, M.D., M.P.H. before the Senate Committee on Labor
and Human Resources. Available at: http://www.hhs.gov/asl/testify/t970425a.html. Last accessed:
January 20, 2013.
16
Grumbach, K., & Mendoza, R. (2008). Disparities in human resources: addressing the lack of diversity
in the health professions. Health Affairs, 27(2), 413-422.
17
Andrulis, D.P., Siddiqui, N.J., Purtle, J.P., & Duchon, L. (2010). Patient Protection and Affordable Care
Act of 2010: Advancing Health Equity for Racially and Ethnically Diverse Populations. Washington, DC:
Joint Center for Political and Economic Studies. Available at:
http://www.jointcenter.org/hpi/sites/all/files/PatientProtection_PREP_0.pdf, last accessed March 4,
2013.
18
Passel, J. S., & Cohn, D. (2008). US population projections, 2005-2050. Pew Research Center. Available
at: http://www.pewsocialtrends.org/2008/02/11/us-population-projections-2005-2050/. Last accessed:
February 26, 2013.
19
Ibid.
20
Smedley, B. D., Butler, A. S., & Bristow, L. R. (2004).In the nation's compelling interest: Ensuring
diversity in the health-care workforce. National Academy Press.
21
American Public Health Association. (2009). Public Health Services Act Title VII and Title VIII: Why
are these programs so important? Available at: http://www.apha.org/NR/rdonlyres/13E647B5-E51B-4A4791A8-652EE973A2DB/0/TitleVIIandTitleVIII.pdf. Last accessed: February 23, 2013.
22
Green, A.R., et al. (2008). Providing culturally competent care: Residents in HRSA Title VII funded
residency programs feel better prepared. Academic Medicine, 83(11): 1071-1079.
23
Rittenhouse, D.R., et al. (2008). Impact of Title VII training programs on community health center
staffing and National Health Service Corps participation. Annals of Family Medicine, 6(5):397-405.
24
American Public Health Association. (2009). Public Health Services Act Title VII and Title VIII: Why
are these programs so important? Available at, http://www.apha.org/NR/rdonlyres/13E647B5-E51B-4A4791A8-652EE973A2DB/0/TitleVIIandTitleVIII.pdf, last retrieved February 23, 2013.
25
Ibid.
26
Ibid.
27
Ibid.
28
U.S. Department of Health and Human Services.(2010, September). News release: HHS awards $320
million to expand primary care workforce. Available at: http://www.hhs.gov/news/press/
2010pres/09/20100927e.html. Last accessed January 15, 2013.
29
Affordable Care Act, Primary Care Residency Expansion (PCRE) Program. Announcement Number:
HRSA-10-277. Catalogue of Federal Domestic Assistance (CFDA) No. 93.510.Funding Opportunity
Announcement. Fiscal Year 2010.U.S. Department of Health and Human Services. Health Resources and
Services Administration.
30
Redhead, C.S., Lister, S.A., Colello, K.J., Sarata, A.K., & Heisler, E.J. (2013, July). Discretionary Spending
in the Patient Protection and Affordable Care Act (ACA). Congressional Research Service, CRS Report for
Congress. (R41390). Available at: http://www.fas.org/sgp/crs/misc/R41390.pdf. Last accessed: March 1,
2013.
31
See Project Abstract for Grant # T89HP20837, entitled “Baylor College of Medicine Family Medicine
Residency Expansion.” Available at: http://granteefind.hrsa.gov/. Last accessed: February 24, 2013.
32
Ibid.
33
Ibid.
34
See Project Abstract for Grant # T89HP20768, entitled “Crozer Family Medicine Residency Expansion
Project.” Available at: http://granteefind.hrsa.gov/. Last accessed: February 24, 2013.
35
Ibid.
36
See Project Abstract for Grant #T89HP20750, entitled “Primary Care Advocacy Leadership Service
(PALS) Program.” Available at: http://granteefind.hrsa.gov/. Last accessed: February 24, 2013.
37
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188
Lie, D. et al. (2010). Does Cultural Competency Training of Health Professionals Improve Patient
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201
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202
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204
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215
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217
Noonan, A., Lindong, I., & Jaitley, V. N. (2012). The Role of Historically Black Colleges and Universities
in Training the Health Care Workforce. American Journal of Public Health, Vol 103, No 3.
218
Ibid.
219
Santoro, K.L. & Speedling, C.M. (2012 July). Investing in the Future Health Care Workforce. Health
Resources & Services Administration’s Maternal and Child Health Bureau. National Institute for Health
Care Management Research and Education Foundation Issue Brief. 1-10. Available at:
http://www.nihcm.org/component/content/article/662. Last accessed: January 14, 2013.
220
Pear, R. (2013, February 24). Panel on Health Care Work Force, Lacking a Budget, Is Left Waiting. New
York Times. Available at http://www.nytimes.com/2013/02/25/health/health-care-panel-lacking-budgetis-left-waiting.html?ref=health&_r=0, last accessed on February 25, 2013.
110